[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
THE OPIOID CRISIS: REMOVING BARRIERS
TO PREVENT AND TREAT OPIOID ABUSE
AND DEPENDENCE IN MEDICARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 6, 2018
__________
Serial No. 115-HL03
__________
Printed for the use of the Committee on Ways and Means
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
33-794 WASHINGTON : 2019
COMMITTEE ON WAYS AND MEANS
KEVIN BRADY, Texas, Chairman
SAM JOHNSON, Texas RICHARD E. NEAL, Massachusetts
DEVIN NUNES, California SANDER M. LEVIN, Michigan
DAVID G. REICHERT, Washington JOHN LEWIS, Georgia
PETER J. ROSKAM, Illinois LLOYD DOGGETT, Texas
VERN BUCHANAN, Florida MIKE THOMPSON, California
ADRIAN SMITH, Nebraska JOHN B. LARSON, Connecticut
LYNN JENKINS, Kansas EARL BLUMENAUER, Oregon
ERIK PAULSEN, Minnesota RON KIND, Wisconsin
KENNY MARCHANT, Texas BILL PASCRELL, JR., New Jersey
DIANE BLACK, Tennessee JOSEPH CROWLEY, New York
TOM REED, New York DANNY DAVIS, Illinois
MIKE KELLY, Pennsylvania LINDA SANCHEZ, California
JIM RENACCI, Ohio BRIAN HIGGINS, New York
PAT MEEHAN, Pennsylvania TERRI SEWELL, Alabama
KRISTI NOEM, South Dakota SUZAN DELBENE, Washington
GEORGE HOLDING, North Carolina JUDY CHU, California
JASON SMITH, Missouri
TOM RICE, South Carolina
DAVID SCHWEIKERT, Arizona
JACKIE WALORSKI, Indiana
CARLOS CURBELO, Florida
MIKE BISHOP, Michigan
DARIN LAHOOD, Illinois
David Stewart, Staff Director
Brandon Casey, Minority Chief Counsel
______
SUBCOMMITTEE ON HEALTH
PETER J. ROSKAM, Illinois, Chairman
SAM JOHNSON, Texas SANDER M. LEVIN, Michigan
DEVIN NUNES, California MIKE THOMPSON, California
VERN BUCHANAN, Florida RON KIND, Wisconsin
ADRIAN SMITH, Nebraska EARL BLUMENAUER, Oregon
LYNN JENKINS, Kansas BRIAN HIGGINS, New York
KENNY MARCHANT, Texas TERRI SEWELL, Alabama
DIANE BLACK, Tennessee JUDY CHU, California
ERIK PAULSEN, Minnesota
TOM REED, New York
MIKE KELLY, Pennsylvania
C O N T E N T S
__________
Page
Advisory of February 6, 2018, announcing the hearing............. 2
WITNESSES
Philip B. Scott, Governor, State of Vermont, accompanied by Al
Gobeille, Secretary of Human Services.......................... 7
Ramsin M. Benyamin, M.D., President and Founder, Millennium Pain
Center, and Board of Directors, American Board of
Interventional Pain Physicians................................. 30
Jason Kletter, Ph.D., President, BayMark Health Services and Bay
Area Addiction Research and Treatment (BAART).................. 42
Harold L. Paz, M.D., M.S., Executive Vice President and Chief
Medical Officer, Aetna, Inc.................................... 51
Laura Hungiville, PharmD, Chief Pharmacy Officer, WellCare Health
Plans, Inc..................................................... 62
QUESTIONS FOR THE RECORD
Questions from the Majority Members of the Subcommittee on Health
of the Committee on Ways and Means, to Ramsin M. Benyamin,
M.D., President and Founder, Millennium Pain Center, and Board
of Directors, American Board of Interventional Pain Physicians. 83
Questions from Representative Adrian Smith, of Nebraska, to
Harold L. Paz, M.D., M.S., Executive Vice President and Chief
Medical Officer, Aetna, Inc.................................... 84
Questions from Representative Judy Chu, of California, to Harold
L. Paz, M.D., M.S., Executive Vice President and Chief Medical
Officer, Aetna, Inc............................................ 85
Questions from the Majority Members of the Subcommittee on Health
of the Committee on Ways and Means, to Harold L. Paz, M.D.,
M.S., Executive Vice President and Chief Medical Officer,
Aetna, Inc..................................................... 86
SUBMISSIONS FOR THE RECORD
Pharmaceutical Care Management Association (PCMA)................ 88
Philip B. Scott, Governor, State of Vermont...................... 93
THE OPIOID CRISIS: REMOVING BARRIERS
TO PREVENT AND TREAT OPIOID ABUSE
AND DEPENDENCE IN MEDICARE
----------
TUESDAY, FEBRUARY 6, 2018
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to call, at 3:07 p.m., in
Room 1100, Longworth House Office Building, Hon. Peter Roskam
[Chairman of the Subcommittee] presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
SUBCOMMITTEE ON HEALTH
CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
Tuesday, February 6, 2018
HL-03
Chairman Roskam Announces Hearing on
The Opioid Crisis: Removing Barriers
to Prevent and Treat Opioid Abuse
and Dependence in Medicare
House Ways and Means Health Subcommittee Chairman Peter Roskam (R-
IL), announced today that the Subcommittee will hold a hearing on ``The
Opioid Crisis: Removing Barriers to Prevent and Treat Opioid Abuse and
Dependence in Medicare.'' The hearing will discuss the ongoing opioid
crisis, and the important role data, addiction prevention, and access
to treatment play in addressing the crisis. The hearing will also
examine possible legislative solutions to combat opioid abuse. The
hearing will take place on Tuesday, February 6, 2018, in room 1100 of
the Longworth House Office Building, beginning at 3:00 p.m.
In view of the limited time to hear witnesses, oral testimony at
this hearing will be from invited witnesses only. However, any
individual or organization may submit a written statement for
consideration by the Committee and for inclusion in the printed record
of the hearing.
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
Please Note: Any person(s) and/or organization(s) wishing to submit
written comments for the hearing record must follow the appropriate
link on the hearing page of the Committee website and complete the
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for
which you would like to make a submission, and click on the link
entitled, ``Click here to provide a submission for the record.'' Once
you have followed the online instructions, submit all requested
information. ATTACH your submission as a Word document, in compliance
with the formatting requirements listed below, by the close of business
on Tuesday, February 20, 2018. For questions, or if you encounter
technical problems, please call (202) 225-3625.
FORMATTING REQUIREMENTS:
The Committee relies on electronic submissions for printing the
official hearing record. As always, submissions will be included in the
record according to the discretion of the Committee. The Committee will
not alter the content of your submission, but we reserve the right to
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and any written comments in response to a request for written comments
must conform to the guidelines listed below. Any submission not in
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All submissions and supplementary materials must be submitted in a
single document via email, provided in Word format and must not exceed
a total of 10 pages. Witnesses and submitters are advised that the
Committee relies on electronic submissions for printing the official
hearing record.
All submissions must include a list of all clients, persons and/or
organizations on whose behalf the witness appears. The name, company,
address, telephone, and fax numbers of each witness must be included in
the body of the email. Please exclude any personal identifiable
information in the attached submission.
Failure to follow the formatting requirements may result in the
exclusion of a submission. All submissions for the record are final.
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with disabilities. If you are in need of special accommodations, please
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four
business days notice is requested). Questions with regard to special
accommodation needs in general (including availability of Committee
materials in alternative formats) may be directed to the Committee as
noted above.
Note: All Committee advisories and news releases are available at
http://www.waysandmeans.house.gov/
Chairman ROSKAM. The Subcommittee will come to order.
Welcome to the Ways and Means Health Subcommittee hearing
on ``The Opioid Crisis: Removing Barriers to Prevent and Treat
Opioid Abuse and Dependence in Medicare.'' I am pleased to take
on this issue, along with Mr. Levin, as my first hearing as the
new Subcommittee Chairman.
This is the second hearing in a series held by the Ways and
Means Committee on this crisis. And today we will explore
opioid addiction and treatment in our Medicare population and
ask the question how Congress can do more to improve detection,
education, prevention, et cetera.
Like many States, my home State of Illinois is experiencing
an increase in opioid-related overdose deaths. According to the
Illinois Department of Public Health, there has been a 44.3-
percent increase in drug overdoses from 2013 to 2016. I know
this figure is consistent with other States and other
experiences. Approximately 80 percent of drug overdose deaths
in 2016 were opioid-related. Nationally, more than 42,000
Americans died from opioid-related drug overdoses in 2016,
according to the Centers for Disease Control. That is over 115
people a day or the equivalent of over 14 people who would have
lost their lives in the course of this upcoming hearing today.
And while those are statistics and the statistics are
compelling, we are talking about sons and daughters, brothers
and sisters, mothers and fathers, and those who are dear to us
who are struggling with this crisis in and around our
communities. With 10,000 baby boomers joining Medicare each
day, we must harness innovation, technology, and data to get
ahead of this problem. Unfortunately, there is a lack of
available data regarding the Medicare population and the extent
to which opioid abuse, overprescribing, and diversion is an
issue for seniors and the disabled. Additionally, gaps in
coverage for those that suffer from opioid addiction exist as
well.
To help us examine what States are doing to address the
opioid epidemic, we have Governor Phil Scott to discuss the
tremendous efforts that the State of Vermont has undertaken to
battle the crisis through expanded treatment options and
substance abuse disorder management. We have representatives
from two health plans that serve Medicare beneficiaries to
discuss how payers are managing care for those that suffer from
substance abuse disorder and the hurdles they face in doing so.
And, finally, to round out our witness panel, we have two
representatives from the medical field to discuss both
medication-assisted treatment and other intervention pain
services.
I think all of us approach this issue with humility. All of
us represent constituencies that are being overwhelmed by this
crisis, and all of us are looking for solutions. And I think
our constituents have sent us here with a disposition to get
things done, and I look forward to working with both sides of
the aisle to come up with commonsense solutions, to look at the
things that work and celebrate them and pursue them, shun the
things that don't work, and to do everything that we can to
relieve this crisis and bring hope and optimism in a field that
is really quite overwhelming.
I am pleased that Mr. Neal, the Ranking Member of the Ways
and Means Committee, is here, and I would yield to him for the
purposes of an opening statement.
Mr. NEAL. Thank you, Mr. Chairman. Let me congratulate you
on your first hearing here. I would remind all that you served
with me on the Tax Subcommittee, and it was very clear that you
decided your future would lie in the Health Subcommittee after
that.
Mr. Chairman, I am pleased that we are holding this hearing
to identify solutions to address the opiate abuse and
dependence specifically in the Medicare space. Although
overdose rates are highest for people 25 to 54, this public
health emergency also affects Medicare beneficiaries. Everyone
in this room has a family member or knows someone directly
impacted by the opiate epidemic. It could be somebody down the
street. It could be somebody in the next room. In my home State
of Massachusetts, last year, there were 2,094 opiate-related
deaths due to abuse. I thank my neighbor to the north, Governor
Scott, and his Health Secretary, Al Gobeille, for joining us
today. We share a border, and it also means that we share a
common challenge in fighting the opiate crisis. Massachusetts
Governor Charlie Baker, like Governor Scott, is working to
employ all tools in this fight, ranging from expanding Medicaid
coverage to provide treatment availability, data analytics, and
treating addiction while stabilizing and supporting families.
Opiate abuse and related deaths take a toll on all of our
communities and on all of our families. There is no single
cause and there certainly is no single solution. Expanding
Medicaid under the Affordable Care Act to low-income working
Americans who previously could not afford insurance has been
the most significant step in recent years to stem the tide of
the opiate crisis. Providing access to critical substance abuse
and mental health services that previously were prohibitively
costly has also worked.
We need to look to Medicare beneficiaries' ability to
access treatment as ofttimes providers aren't available to meet
the needs. We know there are significant gaps in coverage and
access under Medicare. For example, Medicare does not cover
outpatient treatment programs that provide comprehensive opiate
addiction treatments, nor does Medicare cover methadone for
addiction, which is often the treatment of choice for longer
term addicts. I recently introduced legislation that would
allow methadone to be covered for outpatient services under
Medicare.
We also need to work with our partners to identify best
practices. Late last week, I sent a letter to the Energy and
Commerce Ranking Member Pallone about 14 Medicare plans and
asked them to help compile the best practices that they are
aware of to address opiate-related disorders. Evidence-based
tested activities that are helping patients turn the corner
will help us design sound policy. I look forward to these
plans' responses, and I hope Dr. Paz from Aetna today will
share his knowledge about what they are doing as well.
We also need to explore how substance abuse is affecting
children and families. The epidemic is fueling rising caseloads
for children and adult protective services, for foster care,
and also for caregivers as they attempt to battle addiction.
I am pleased that our Committee has worked together on this
bipartisan basis on legislation to support families and to help
them keep children safe who would otherwise be in foster care
while they can now remain safely at home with proper
monitoring. We hope we can continue this partnership because we
have much work to do.
I hope as we move into the following year that we will not
endorse or embrace plans to cut efforts that would, in fact,
undermine what we are attempting to do here today. For example,
the Social Security--Services Block Grant is the largest source
of Federal funding for child protective services and the only
major source of Federal funding for adult protective services
in most States. We have a lot of work to do, and Congress could
play a positive role in partnering with the States to provide
resources and help to eliminate Federal barriers to treatment
and access and support families and law enforcement.
And, Mr. Chairman, to you for holding this hearing, I
appreciate it. I also point out something that you and I have
talked about a number of times. There are now 2 million people
on the sidelines who formerly were in the workplace battling
this epidemic. When you look at labor participation rates, it
has had a huge impact on what has happened. So this is a very
important hearing. Thank you.
Chairman ROSKAM. Thank you, Mr. Neal.
I now recognize Mr. Levin for his opening statement.
Mr. LEVIN. Thank you, Mr. Chairman, and congratulations. We
all look forward to working with you. You are surely a very
articulate, knowledgeable person. We look forward to it. And
thank you for letting us, in essence, make two opening
statements. Mr. Neal comes from a State, I think, where there
has been a strong wrestling with this issue. The same in
Michigan.
Welcome to the witnesses. A son, Matthew, lives in Vermont
and is active representing mainly education groups. In the
halls, he may have bumped into you.
Mr. Chairman, the opioid epidemic is an enormous societal
problem that demands a concerted effort at every level of
government. The death toll is astonishing. Ninety-one Americans
die every day from an opioid overdose, with five dying every
single day in my home State. We have to stop this killer.
Despite the urgency of this crisis, it is clear that, although
President Trump has declared a public health emergency, to
date, the Administration has not taken significant steps to
address it.
Last year, President Trump proposed a budget that would
radically alter the Medicaid program while slashing its funding
by
$1.3 trillion. Medicaid is the largest payer for behavioral
health services. It funds detoxification, maintenance therapy,
medication-assisted treatment, and other crucial services. We
cannot claim we are serious about addressing this crisis on the
one hand while gutting one of the country's most important
sources of treatment on the other.
These efforts come on the heels of efforts within the
Affordable Care Act that would have, I think, if repeal had
occurred, undermined these efforts. I will look now to the
future and leave those comments for the record.
At this crucial time, the Administration has also
undermined the Office of National Drug Control Policy, which
for decades has helped fight drug abuse in this country. Last
year, we fought against the Administration's efforts to
eliminate all funding for the Drug-Free Community Program, an
effective multisector community-based drug prevention program
that was really started by a fellow Member of this Committee,
Rob Portman, when he served, and myself in 1996. There have
been thousands of community antidrug coalitions that have
received seed money because of this program. The appropriation
level now is $90 million.
This year, we heard once again that the Administration
intends to propose undercutting this office by eliminating its
oversight of drug control and prevention programs. And I must
confess, I was really alarmed, like so many, when the
Administration suggested placing a 24-year-old with no relevant
experience in the second highest position. Through the Drug-
Free Communities Act, we have had so much contact with this
office. It needs the most talented personnel effort.
A coordinated Federal response to this crisis is possible,
but it will require a dramatic change of course. We must take
immediate steps to ensure that we are effectively implementing
programs that prevent flooding of our communities with
unnecessary prescriptions. In Michigan, a State of less than 10
million, more than 11 million opioid prescriptions are written
annually, 11 million. This is more than enough to provide each
resident of my home State with a bottle of opioids each year.
Addressing the pervasiveness of this will require a broad-
based effort to revise clinical guidelines with the goal of
improving provider behavior, leadership at the State and
Federal level to monitor for harmful prescriptions and
marketing practices, and other immediate steps that will reduce
the prevalence.
I just close. We all, Mr. Chairman, encounter this problem
every time we go home, do we not? Every time. And we hear of
deaths. It is younger people, but also people not so young,
people sometimes under immense stress.
And I think with the leadership of this Subcommittee and
the entire Ways and Means Committee, Energy and Commerce, and
the Congress, we need to do everything to fulfill our
obligation. All the answers aren't in Washington, but some of
them are.
So we look forward to the testimony of you distinguished
members of the public sector. Thank you, Mr. Chair.
Chairman ROSKAM. Thank you, Mr. Levin.
Let me describe how we will move the traffic today. We have
two panels. The first panel will be the Governor. And we will
have 5 minutes from each of the witnesses. If you are getting a
little lengthy, I will tap my gavel gently. But I think most
folks have had an opportunity to read all of the statements.
To give us an introduction of the Governor is the
distinguished gentleman and our friend from Vermont, Mr. Welch,
who has this distinguishing gift of being able to tell someone
to go jump in the lake but with such charm that you kind of
look forward to the trip, actually.
So, Mr. Welch, would you----
Mr. LEVIN. And there aren't that many lakes in Vermont,
either.
Chairman ROSKAM. Could you introduce the Governor?
Mr. WELCH. I thank the Chairman for that dubious
introduction, but I am not here to tell you to jump in a lake.
I am here to thank you for having a bipartisan hearing on an
incredibly devastating problem. And, as Mr. Levin said, we here
in the Federal Government can provide some help, but the hard
work is done with first responders, with Mayors, and with
Governors.
One distinguishing thing about Vermont is we embraced the
challenge on a bipartisan basis. The Democratic Governor,
predecessor to Phil Scott, Peter Shumlin, spoke in his entire
address in 2014 about the opioid crisis. And I remember talking
to some of my colleagues here, saying, ``Peter, why would you
be advertising that bad news,'' but then, as we talked,
acknowledging that that was a devastating issue in their own
communities.
Phil Scott was then Lieutenant Governor. He has taken up
the leadership in Vermont now to follow through, and we have
this bipartisan approach to try to address the tragic
circumstances of opioid addiction.
So I thank all of the Members of this Committee.
Mr. Chairman, thank you for being here.
Ranking Member Neal is here as well. It shows the urgency
of this Committee.
And all of us are ready to work with you. Thank you.
And I give you the Governor of the State of Vermont, my
friend, former Lieutenant Governor, now Governor Phil Scott, of
Middlesex, Vermont.
Chairman ROSKAM. Governor, you are recognized. Thank you
for being here.
STATEMENT OF PHILIP B. SCOTT, GOVERNOR, STATE OF VERMONT,
ACCOMPANIED BY AL GOBEILLE, SECRETARY OF HUMAN SERVICES
Governor SCOTT. Thank you very much.
And thank you, Congressman Welch. We served together in the
Senate not long ago.
Chairman Roskam, Ranking Member Levin--I do know your son.
I played hockey with him a few years ago. He is a very good
hockey player--and Members of the Subcommittee, I want to thank
you for the honor of appearing before you today. My Secretary
of Human Services, Al Gobeille; Commissioner of Health, Dr.
Mark Levine; and the Director of the Blueprint for Health, Beth
Tanzman, are here with me as well.
As was mentioned, in Vermont, the Governor and Lieutenant
Governor are elected separately. So, in 2014, when then-
Governor Peter Shumlin, a Democrat, devoted his state of the
State address to the opioid epidemic, I was sitting there
listening as the Republican Lieutenant Governor. And I must
admit, I was more than just a bit skeptical. I was concerned
calling so much attention to this problem would damage our
image and hurt our State. And sure enough, initially, many at
the national level portrayed this as only a Vermont problem. We
now know all too well this was and is a national problem.
Governor Shumlin was right to focus our attention on this
epidemic, and I have since learned the incredible devastation
opioids have had on our State and our people. I have met
countless Vermonters impacted by addiction, some in recovery,
some still struggling, and some who have had their families
torn apart, changing their lives forever.
We have made a lot of progress in Vermont, much of it with
support from you and our Federal partners, although, today, I
approach you humbly because we have not yet solved this
problem. Even with our small population, we see two Vermonters
die from a drug overdose every week. And nearly every day a
baby is born exposed to opioids, something I have highlighted
as one of Vermont's biggest challenges.
We have some of the best access to treatment in the Nation,
but too many Vermonters who need treatment have not sought it.
And while Vermont's rate of overdose deaths is the lowest in
New England, we still lost 106 people in 2016. In 2017, it
looks like it will be similar. Tragically, we also experienced
high numbers of children under the age of five who come into
State custody due to this crisis. And I think we all would
agree these kids don't deserve this. They need a better start.
We have focused on what I refer to as the four legs of the
stool: prevention, recovery, treatment, and enforcement. My
first day in office I established by executive order the Opioid
Coordination Council. This Council is made up of a wide range
of perspectives, life experience, and different political
philosophies. Importantly, this includes those who have
suffered from the addiction themselves. I handpicked them and
tasked them with providing recommendations to improve Vermont's
response to each of the four legs of the stool.
We know that too many Vermonters become addicted through
prescription pain medication. Therefore, the State implemented
strict prescriber rules around pain management and a
prescription monitoring system. So, for the first time, we are
beginning to see a reduction in prescribed opioids.
Unfortunately, we still prescribe three times as much as we did
in 1999.
Vermont has also made Narcan widely available to first
responders, law enforcement, people with addiction, and family
members of those suffering. We have aggressively used a
screening, brief intervention, and referral to treatment model,
also known as SBIRT, to prevent the progression of addiction.
Enforcement is another important piece, but we are all in
agreement: we can't arrest our way out of this. Our courts,
local police, and States attorneys have become important
partners in addressing this epidemic, and we address it as a
public health issue.
To treat opioid addiction, Vermont operates a medication-
assisted treatment, or MAT system, called Hub and Spoke. With
the support of our Federal partners, we established a help home
for Vermonters with opioid addiction. Through well-coordinated
and comprehensive services, we treat opioid addiction like we
do any other chronic condition. Our Hubs provide all FDA-
approved medications. They also provide critical nursing,
counseling, and care management. In our Spokes, primary care
offices prescribing buprenorphine are supported by nurses and
counselors who offer more complete care. Finally, coordination
between Hubs and Spokes assures the patients receive the
appropriate level of care as they need it.
Vermont and the Federal Government have been effective
partners in tackling healthcare challenges for many years. It
is in this collaborative spirit that I offer four areas where
together we can improve our response:
First, Medicare needs to treat this as the chronic
condition that it is. I have sent a letter to the Secretary of
Health and Human Services asking that CMS work with Vermont and
engage Medicare in Vermont's Hub and Spoke system. Working with
our Federal partners, we hope to develop a path to make this a
reality.
Second, we need to make sure that SBIRT is fully supported
within the billing system so Vermont can sustain and expand
this important work.
Third, we ask you to consider giving States relief from the
IMD exclusion, which prohibits using Medicaid funds in mental
health or treatment facilities of 16 or more beds.
Finally, our small State could benefit tremendously from
nationally supported research in the areas of alternative pain
treatment and from expanded coverage for alternative chronic
pain management.
In closing, I would like to thank you for the opportunity
to address this Committee. We have made great progress over the
years, but we have much more to do if we are to improve the
health of Vermonters and all Americans to truly end this crisis
and this epidemic.
Thank you.
[The prepared statement of Governor Scott follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman ROSKAM. Thank you, Governor. We really appreciate
your insight. Don't go anywhere. I am now going to briefly
introduce the other panelists for a little bit of a
foreshadowing, and then we are going to come back for questions
with you.
So for our second panel, we are going to hear from Dr.
Ramsin Benyamin, President and Founder of Millennium Pain
Center, lo-
cated in Bloomington, Illinois. We look forward to hearing from
him.
For our next few witnesses, I am going to yield to our
colleagues. I will now yield to Mr. Thompson for the purpose of
an introduction.
Mr. THOMPSON. Thank you, Mr. Chairman, and congratulations
on your new Chairmanship and thanks for having this hearing.
Mr. Chairman, thanks for the opportunity to introduce and
to welcome to the Committee Dr. Jason Kletter, the President of
BayMark Health Services. Dr. Kletter has 20 years of experience
in the addiction field and currently serves as President of the
Bay Area Addiction Research and Treatment, headquartered in San
Francisco in the bay area. His organization operates 20 opioid
treatment programs in five States, serving 7,000 patients every
day. Dr. Kletter also serves as the President of the California
Opioid Maintenance Providers and as a board member of the
American Association for the Treatment of Opioid Dependence. He
has advised both Federal and State agencies, providing input on
accreditation guidelines, physician training, and various State
policies.
As part of California's Hub and Spoke program, modeled off
the program Governor Scott described earlier, Dr. Kletter's
BAART program in Antioch, California, will serve as the Hub to
a handful of Spokes that will provide treatment to constituents
across my district. And I just learned today he is also a part-
time resident of my hometown.
So, Dr. Kletter, thank you for your testimony. I look
forward to hearing about your experience in the field and
understanding how this Committee can best support your work.
Thank you for being here.
Chairman ROSKAM. Thank you, Mr. Thompson.
Mr. Larson.
Mr. LARSON. Thank you, Mr. Chairman. And let me echo the
sentiments of the Members of the Committee and congratulate you
on your new Chairmanship. And I know how well you work with Mr.
Levin, and we thank you for hosting this very important hearing
today.
It is my honor to introduce Dr. Harold Paz, who is the
Executive Vice President and Chief Medical Officer for Aetna in
my home State of Connecticut.
Aetna is blessed that it has probably one of the leading
thought leaders around healthcare in the world in Mark
Bertolini, and Connecticut as a region is blessed to have an
industry that is focused on this, including David Cordani from
Cigna as well. But as head of the Aetna's enterprisewide opiate
task force, Dr. Paz is responsible for a companywide strategy
to prevent the misuse and abuse of medications, something that
is critical in this epidemic as it continues to wreck, savage
this country of ours.
Under his leadership, we have been able to follow examples
and hope that we are able to follow examples that the private
sector is setting, find ways to help our public health system,
especially Medicare and Medicaid, and effectively and humanely
care for those suffering from addiction. Aetna has used its
valuable data to help identify what they call super-prescribers
and work with hard-hit States to provide training and supplies
of lifesaving treatments, like Narcan, as the Governor
mentioned early on.
So it is my high honor here today to introduce Dr. Paz. We
look forward to your testimony, and we thank you for your
leadership and acknowledge it is not just government but the
private sector and, in fact, all of us that need to work in
collaboration to solve this national epidemic.
Thank you, Dr. Paz.
Chairman ROSKAM. Thank you, Mr. Larson.
And Mr. Buchanan.
Mr. BUCHANAN. Thank you, Mr. Chairman, for holding this
important hearing. I also want to congratulate you on your
Chairmanship. I am excited about what you are going to be able
to do with this Committee.
I am pleased to welcome Laura Hungiville, Chief Pharmacy
Officer of WellCare Health Plans based in Tampa, Florida, part
of the region that I represent. They do a lot in our region,
and throughout the State and the country. In this role, she
helps implement programs to prevent opioid abuse, helps members
living with chronic pain, and helps members battling addiction.
WellCare insures 4.3 million members nationwide enrolled in
Medicare Advantage, Medicare prescription drug plans, and
Medicaid. Currently, this does not include mental health
counseling, yet according to the HHS, approximately 13 percent
of people age 65 and older suffer from mental illness.
And, with that, I yield back.
Chairman ROSKAM. Thank you all.
Now we will turn to make inquiries of the Governor and his
team. We are going to break with our normal tradition and, by
agreement, we are limiting our Members to 4 minutes.
And, with that, I yield back to Mr. Buchanan to begin the
inquiry.
Mr. BUCHANAN. Thank you, Governor, for being here. We also
have a Governor Scott in Florida, and I don't know if you are
related or not, but if you are nearly as talented as he is, you
have to be a heck of a Governor.
Governor SCOTT. If there is any controversy, I usually
blame him.
Mr. BUCHANAN. Let me just say, about 7 or 8 years ago, I
had a lot of members from Kentucky and Tennessee and other
places, and everybody would be coming to Florida. We had 1,300
pill mills that were here, and they had come here because we
didn't have a database. And it was a disaster. We were losing
10 people a day. We have shut down a lot of those pill mills,
but they have moved over to heroin and fentanyl and other drugs
in our community. In fact, my main county is the epicenter of
Florida per capita with a lot of these drugs.
But I read something the other day. It just was a shocking
statistic from the AARP on deaths from opioids. Of course,
being in Florida, we have a lot of seniors. I think 60 percent
of my constituents are 60 and older in my area. But deaths from
opioids, they have increased seven times for a senior 65 to 74,
because you always think sometimes about just younger people,
over the past 15 years. This is an absolute tragic thing. And I
guess I would be interested in what you have learned from
Vermont, in terms of a lot of your seniors. Let's just take
that initially, any thoughts that you have on that.
Governor SCOTT. I will start off and then let my Secretary
take over from there. But we are seeing--I think a lot of it is
the prescription rate amongst seniors across the board that
they store in their medicine cabinets and so forth. We have a
drug take-back, a prescription drug take-back program, where in
the first--what I thought was the first year they collected
almost 6,000 pounds in our small State of Vermont. And I
thought that was remarkable and that, for the first year, I
would expect that with the pent-up reserves. And then they told
me that was the third year, and they collected 5,000 the year
before and 5,000 the year before that. So that tells me that
the prescription rate is abusive and excessive.
So I don't believe we are seeing the deaths of our seniors
as we do with our youth, but I will let our Secretary answer
that.
Mr. BUCHANAN. Just for time, let me get to another
question. I think one of my colleagues had mentioned how
everybody is impacted. My family has been impacted. But what
are you doing on a little different score? What are you doing
in terms of prevention? I had a mother come in the other day,
four kids, homeschooled, two of them are addicted.
So the thought to me is, what do we do to prevent this in
the first place? Because once they go through that door--she
told me, crying, that after 2 weeks of being on these pills,
the older brother brought it home and got his sister hooked. In
a matter of a couple of weeks, they got addicted. It has been
over a year for both of them to be able to get off this stuff,
and they might have to deal with this for the rest of their
lives.
So the impact and the power of these drugs is incredible,
but I have a lot of stories like that. I have had three mothers
come in where they have lost their children, and that is what
got me initially involved in this effort.
But what is your thought about prevention? Because once
they go through that door, in my opinion, it is nice to have
all these other things and it is important, but how do we
prevent it in the first place? What more can we be doing on the
prevention front?
Mr. GOBEILLE. Thank you. My answer to that would be, we
need to do a lot more in prevention. Some of the things that we
have done is that we have worked with the goal of setting up a
prescription monitoring system in our State. We passed a law in
2013. But we had done good work prior to that to try to get a
database where we would know what specialties we are
prescribing, at what levels, basically so that doctors would
know who was prescribing what to their patients so that we
could look inside our State, but also, because we are a small
State, to our neighboring States and what was happening with
our patients, basically, that could go there for pills. So it
is a game of, how do you reduce the impact of the pills,
because this is a pill-driven crisis? And so anything that can
aid that upstream has a big benefit.
Mr. BUCHANAN. Let me just close out, because I want to
yield back.
Chairman ROSKAM. Thank you. Let me just give you a little
housekeeping here. I think we as Members have a lot to say. We
are going to be well-served if we allow our witnesses to give
us input. And so keep the time on your question a little more
limited so that they can come back. You know what I am saying?
We are varying from our normal procedure.
Mr. Thompson.
Mr. THOMPSON. Thank you, Mr. Chairman.
Governor, thank you for being here. According to the CDC,
42 percent of workers with back injuries got an opioid
prescription in the first year after their injury, and then a
year later, nearly one in five of those patients are still
taking the same drug, despite the fact that the FDA has not
approved opioids for long-term use. So, clearly, these people
are still suffering serious pain or they are addicted.
So how do we make sure that folks, workers who have been
injured on the job and are under the protection of the State
workers' comp system are getting appropriate treatment for
their injury, and how can we ensure that they have access to
treatment if they become addicted?
Mr. GOBEILLE. Thank you. I think that the answer begins
with taking a look at the way that pain clinics are formed, and
I think you have a witness that will come up and describe it
way better than I can. But, basically, there has to be a lot
more avenues to treat the pain and to treat the rehabilitation
for folks other than just opioids.
So, while opioids may be an answer, there are a lot of
other answers that need to--questions that need to be asked and
potential remedies other than just simply prescribing long-term
opioids.
Mr. THOMPSON. Have you looked at the workers' comp system
in your State? I know in my State, I have constituents who
become injured and it takes forever to get through the system,
and they rely on the opioids to relieve the pain while they are
waiting for treatment, sometimes treatment that never comes.
And I am just concerned that this may exacerbate the entire
program.
Governor SCOTT. I have lived that life. I was three decades
in the construction business, so I had numerous of my employees
out with injuries and so forth. And we have to be very, very
careful. Once we open the door and they are prescribed opioids
and the prescription drugs, to just shut them off without
proper treatment leads them to other methods of heroin,
fentanyl, and so forth. So we are monitoring that. We are
taking a look at that as we speak with interest as to what we
can do to make sure that we have a pathway for them to recover
because, again, we don't want to just shut them off. We want to
help them get through it so they can become more productive
citizens back into the workforce, which is so important.
And those are some of the opportunities that we see with
our Opioid Coordination Council, to look for ways that we can
break down the stigma as well as to appreciate when someone has
a problem so that we make sure--again, we want to make sure
that we reintegrate them back into the workforce, because we
desperately need them in Vermont.
Mr. THOMPSON. Thank you. Some have said that Medicaid
expansion is behind the opioid epidemic, but everything that I
have read suggests that the expansion happened in 2014, and
this has been going on since the nineties.
So, Governor, can you tell us about the role Vermont's
Medicaid expansion is playing in your State's efforts to
address this epidemic, and just how critical will Medicaid be
in the recovery process?
Mr. GOBEILLE. Yes. So, to be clear, we don't believe that
Medicaid expansion caused this crisis. And, further, if we
believe through fact that this is a chronic illness, then each
payer should treat it like the chronic illness it is and be
able to pay as a benefit for necessary treatment, counseling,
et cetera. This really started in the late nineties, and I
think that the evidence is clear.
Mr. THOMPSON. Thank you very much. I yield back.
Chairman ROSKAM. Mr. Smith.
Mr. SMITH. Thank you, Mr. Chairman. Thank you to our
witnesses for addressing what I think is a large problem across
the country, both rural and urban. A lot of folks, as you know,
are impacted.
Governor, I am wondering if you think that the type of
management and monitoring necessary to successfully guide
patients through the process of medication-assisted treatment
programs such as yours are possible under the Medicare program.
Feel free to answer, either one of you.
Mr. GOBEILLE. We do think they are possible, but the letter
that we sent the HHS Secretary was basically a request not that
Medicare just simply treat this like a chronic illness and
begin to pay for the delivery of services, counseling, or
medication-assisted treatment, for example, but to actually
participate in Vermont's system of care, which is partially Hub
and Spoke but also other treatment modalities.
So it is not enough to just sort of pay the bill. It is
about the way in which the services are delivered and organized
that we want Medicare to fully participate in like other
payers.
Mr. SMITH. Okay. I think you have answered my next
question, so I appreciate that. And I think the approach--I
would hope that there is the flexibility offered to States to
address as they see fit that not often comes from the Federal
Government, but hopefully that can be offered in the future, if
you will.
Mr. GOBEILLE. Yes, sir. And what I would add is that
recovery and healing should be a part of a conversation with
your healthcare provider. And Hub and Spoke might be one
answer. There might be residential treatment. There might be,
you know, other paths to sobriety and getting back to living
the life you wanted to live. And so Medicare should participate
in all of that, just like we do with other, you know,
illnesses.
Mr. SMITH. There are a lot of Nebraskans, especially in the
agriculture community, who are buying their health insurance
through the individual market. They are telling me that their
out-of-pocket expenses are $30,000 to $40,000 a year, with
copays and deductibles contributing to that. That really puts a
lot of access out of reach.
And I am wondering if that will ultimately pose a barrier.
Certainly, many of our hospitals are even getting stuck with
those copays, unpaid copays and deductibles. And I am wondering
how we might need to address that at the same time we are
looking at these issues.
Mr. GOBEILLE. So just an idea. The way that we treat
colonoscopies, the way that we treat primary care services
under the Affordable Care Act is that those are included, you
know, as a benefit. Services like this could be included and
not necessarily go against your deductible.
And so it is a question of, you know, how you want to set
up the insurance marketplace so that people actually
participate, you know, in different types of prevention
alternatives. And, you know, that would be, you know, for
others denied, but I would think we would have to take a hard
look at that.
Mr. SMITH. Okay, very well.
Thank you. I yield back.
Chairman ROSKAM. Mr. Kind.
Mr. KIND. Thank you, Mr. Chairman, and I welcome you and
congratulate you on your new position. I look forward to
working with you.
Gentlemen, thank you for being here. And I, in particular,
have been paying very close attention to the challenge you face
in Vermont. I mean, you have a large rural State. I have a very
large rural district in western Wisconsin. We face many of the
same issues, and we appreciate your insight on this.
And I also, Governor, appreciate your opening comments, as
a former special prosecutor who dealt in the drug world for a
long time. I have had a lot of forums, a lot of listening
sessions back home, including with law enforcement, and I
haven't met anyone yet who thinks we are going to be able to
deal with this through the criminal justice system. This has to
be a public health approach ultimately to break the cycle of
addiction for us to have any fighting chance to get out ahead
of that. So I appreciate your insight on that.
Governor, I was wondering if you have been following
closely the Trump Administration's Commission on Combating Drug
Addiction and the Opioid Crisis, because last November, they
did come out with a fairly detailed report and findings and
recommendations that were submitted to us here in Congress for
our consideration. Have you had a chance to look at that or
review that at all?
Governor SCOTT. Yes. Our team has taken a look at that. We,
again, have set out on our own course that we think is working.
Some of them were replicated within the report. But we are
always looking for new information.
And, again, one size doesn't fit all, as we have found out.
And there are always new opportunities to do something better.
So we are still looking at the report, determining if there is
anything that we can use to make better use of our system.
Mr. KIND. Some of the recommendations are kind of
commonsense principles that do apply across the board. I mean,
increasing access to substance abuse treatment programs. We are
going to hear further testimony today on that. Also, under
Federal law, insurers are already required to cover addiction
treatment and mental health services. Many of them aren't, and
many of them aren't including them within their networks. And
it is especially difficult in rural areas, given what is
available out there. They also recommended dedicating more
money for treatment overall. They are encouraging greater use
of alternative and complementary forms of medicine, rather than
just a cocktail of prescription drugs that often lead to
addiction and then contributing to the opioid epidemic.
One of the recommendations--I am wondering if you had a
chance to look at it or have an opinion--is recommending that
we give the Department of Labor the authority to start
penalizing insurance companies that aren't including it in the
network and are not adequately providing coverage for addiction
treatment or other mental health services.
Is that something we ought to be considering?
Mr. GOBEILLE. So what I would say is that while they were
holding their meetings and writing their report, our Opioid
Coordination Council, which I chaired, we were writing a report
as well. And we came out almost the same on so many issues. It,
you know, really came out right at the same time. And the NGA
also has a report. So there is a lot of common sense in all the
documents. So I agree with your points.
The last question that you asked, I think that we have to
embrace this as a chronic condition. And then, if we do, we
should make Medicare, Medicaid, and commercial insurers treat
this as an essential health benefit, like we would kidney
disease or diabetes or some other chronic condition.
So yes, I would think that would be----
Mr. KIND. The other thing I think we ought to be
considering is, since you guys are out front doing a lot of
good work and trying to get out, and virtually every State is
trying to do the same thing, is some type of national
repository of best practices and best evidence medicine, what
is working and what isn't, so each State isn't required to, you
know, recreate the same wheel over again.
Interesting. Even though we have been going through
problems with VA reform lately, we have had some success in a
bipartisan fashion implementing certain reforms with the VA
Medical Center, especially when it comes to pain management and
drug addiction. In fact, in my home area, Tomah, Wisconsin, the
VA Center is developing a really interesting model with a
tremendous track record of proven results that could become a
model of care throughout the country if we do it right. So I
would also take a closer look at what the VA has been doing on
this front for some time.
Thank you, Mr. Chairman.
Chairman ROSKAM. Hold that thought and kind of weave your
answer into an inquiry that is coming from Ms. Jenkins from
Kansas.
Ms. JENKINS. Thank you, Mr. Chairman.
And thank you, Governor, for being with us on the
Subcommittee. Like Vermont, my home State of Kansas is
struggling with a nationwide opioid epidemic. In my view, it is
particularly difficult for rural States to expand access to
opioid treatment services, just because of a lack of treatment
facilities and trained medical personnel. So Vermont's Hub and
Spoke approach may very well be a model for our Nation.
In your written testimony, you mentioned strategies for
prevention, harm reduction, early intervention, criminal
justice, treatment, and recovery. Your testimony brought to
mind just a couple questions I would like to ask.
The first is that it is my understanding that there is a
low uptake in the electronic prescribing of controlled
substances. Is the State of Vermont doing anything to encourage
prescribers to utilize e-prescribing and, if so, can you just
talk a little bit about any pushback the State may have
received in implementing those proposals?
Mr. GOBEILLE. I had to phone a friend. We use e-
prescribing, and according to the smarter people than me behind
me, we are good in that area even though we are rural and
small. And so we could get you more information and submit that
in writing, if that would be okay.
Ms. JENKINS. I would be interested if you had any pushback.
Yeah, if you could get back to me, that would be great.
Mr. GOBEILLE. But about the pushback, I think what is
interesting, the way the Congressman from Vermont was
introduced as somebody who could, you know, politely tell
somebody to jump in a snowbank, in Vermont, it is really hard
to fight back common sense, because we are so small and we all
know each other. And so we don't run into that as much as you
might think.
Ms. JENKINS. Okay. I am told that substance abuse community
clinics and residential treatment centers still use telephone,
paper records, and faxes to communicate with each other and the
larger medical systems. I have introduced H.R. 3331 with my
friend, Congresswoman Doris Matsui, that would authorize a
health IT demonstration for behavioral health providers.
Do you think electronic health records can play a role in
States' efforts to combat the opioid crisis? And how is it the
State of Vermont is using electronic health records?
Governor SCOTT. The simple answer is yes.
Mr. GOBEILLE. No, the simple answer is that is brilliant.
So I am a restaurant owner, got into this, you know, sort of
later in life. He was a construction company owner. And we
thought we were behind the 8-ball in terms of being modern
until we really got to work in healthcare. I mean, I haven't
seen a fax machine or a typewriter in a long time, but you can
find them in some behavioral health clinics and some doctors'
offices.
So the point you are making is right on target. There is
not the electronic systems that are necessary to run our
community mental health agencies and the like at the level that
most people would think they would have, FQHCs as well, et
cetera.
Governor SCOTT. I would like to offer as well that when we
talk about some of the treatment centers in our rural areas, it
does put a burden on many who are seeking treatment. And when
you think about in some of our rural sections, we had a waiting
list in one area of 700 waiting for treatment. And that doesn't
lend itself well for those seeking treatment when they have to
be put on a waiting list.
As well, those who were in treatment at that time, it was
so far away that they would spend 2 hours driving to or taking
a bus going to a treatment center to receive their treatment on
a daily basis, 2 hours one way and then 2 hours back, an hour's
worth of treatment. So, for those who were expecting to
reintegrate into the workforce and be part of society again, it
doesn't lend itself well when you are trying to take care of
your family and to find a job where it is flexible enough so
you can receive treatment.
So it is something--we did put a Hub in that area. We
reduced that level from 700 to zero. We don't have a waiting
list in that area anymore, and that is successful. I mean, that
was a time when we took a moment to celebrate success because
you don't have much success in some months. But that was a time
when we said we are doing something fruitful in a positive way.
Chairman ROSKAM. Thank you.
Ms. Sewell.
Ms. SEWELL. I want to thank the Chairman and Ranking Member
for hosting today's forum.
As many of us have seen, more Americans died from drug
overdoses in 2016 than the number of those lost in the entirety
of the Vietnam war. And preliminary data from CDC suggests that
2017 was even worse than 2016.
I want to thank you, Governor Scott, for your leadership on
this topic as well as your testimony today. It is my hope that
more States, including my own State of Alabama, will realize
the successes achieved in Vermont and implement similar
strategies to tackle this growing epidemic.
You spoke a little to your administration's focus on the
importance of helping people in recovery return to gainful
employment. I, like you, Governor Scott, have met with many
people who are in recovery who tell me that it is the dignity
of a job that keeps them going and that keeps their families
going as well. So I think it is really important that we have
models that stress the importance of getting gainful employment
even when you are still in treatment, as you suggested earlier.
The way we address this public health crisis will serve as
a model for decades to come on addiction treatment. I believe
we made a terrible mistake in the 1980s as a country in our
response to the crack cocaine epidemic, where we are seeing
that the response we gave was for more jails and not for more
treatment centers.
I am very happy that, with this epidemic, we are seeing
that it truly is a public health crisis, and it is a crisis
that requires intergovernmental help and lots of wraparound
services, and so figuring out how we can get best practices I
think is really important.
An issue I worked a lot with in my rural areas is
transportation. And so often getting access to treatments has
been a big problem in the State of Alabama. In fact, I
introduced a bill with Congressman Meehan. It is a bipartisan
legislation that would allow Medicare Advantage plans to offer
a wider array of supplemental benefits to chronically ill
enrollees, such as transportation and nutrition programs and
mental health services. I believe we should implement this type
of benefit expansion across Medicare programs.
So I guess my question to you is, Governor Scott, would you
recommend expanding coverage for treatment in Medicare, and can
you explain why you believe improved Medicare coverage for
treatment of opioid abuse is important in fighting this
epidemic?
Governor SCOTT. Absolutely. I am going to let our Secretary
answer, fill in the gaps, but I did want to mention that is
what the beauty is of this Hub and Spoke model, that we can
have treatment facilities closer to those who need it. And when
we see an area, such as we did, that needed more treatment, we
set up another Hub. So it is essential that we react every time
that we see an issue.
I would also say, with the introduction and the use of
Narcan in our State, I am afraid that the number of deaths that
we are seeing, which is almost the same as the previous year,
doesn't tell the whole story, because we are preventing a lot
of deaths from happening. So that doesn't mean that--just
because they are staying the same doesn't mean that we are
necessarily making a lot of ground up. So we have to fulfill
that.
Stigma is an important part of reintegrating, again, those
into the workforce. And I think we have made some positive
gains in that respect. A lot of employers we are speaking with,
we are making a concerted effort through our Labor Department
to try to determine--you know, give those folks a second chance
or third chance or fourth chance, because sometimes it is not
the first time or the second time; it is the third time.
I had employees of mine that we all are aware, more aware
now than we were then, that were addicted, and I didn't know
it. And they were great employees. And so we gave them that
chance, that opportunity to succeed.
Ms. SEWELL. Thank you.
Chairman ROSKAM. Mr. Marchant.
Mr. MARCHANT. Thank you, Mr. Chairman.
Governor, you spent some time in the legislative branch. Do
you think that your State has passed sufficient laws and
statutes to give you the tools that you need to combat this? I
have three questions. I will ask all three of them.
Second, who in Vermont recognizes this dependency? Is it
the State? Is it the doctor? Is it the person themself that
recognizes that they are addicted, or is there a definition
that the State has?
And the last question is, is most of the acquisition of the
opioid legal or illegal?
Mr. GOBEILLE. Sorry, sir?
Mr. MARCHANT. The acquisition of the pills. I mean, are
they getting the pills legally, or are they buying them on the
black market or from a dealer, as a percentage of the people
that are----
Governor SCOTT. I will try to answer some of those and,
again, I would ask my Secretary to fill in the gaps. But what
we are seeing is a lot of the crime rate is due to obtaining
some of the prescription drugs even and some of the unused
prescription drugs in medicine cabinets. That is why the take-
back program is so necessary. Those who have been utilizing
opioids, their kids get involved. They take the drugs. They
sell them or utilize them themselves. That is an issue.
I am trying to recall the rest of your question.
Mr. MARCHANT. Has your legislature passed the statutes that
you need?
Governor SCOTT. Continually. I think we have a good working
relationship. Again, I have served in the Minority, but we have
always worked together, trying to do whatever we can, because
we recognize this isn't a partisan issue. This is an issue that
faces each and every one of us. It doesn't discriminate.
Whether you are Republican or Democrat, it doesn't
discriminate. It doesn't discriminate from a social standpoint
either. So we recognize that, and we have been given many of
the tools, and we continually seek resolutions to try to obtain
more.
Mr. GOBEILLE. And I think the last question you asked is,
what door do you walk through to get treatment in Vermont? And
we try to----
Mr. MARCHANT. Who declares that you need treatment? Is it
usually self-declared or----
Mr. GOBEILLE. So what I would say is that, for treatment to
work, it pretty much has to be self-declared, meaning on a base
level, it has to be a recognition that the person has to make.
But, also, through the screening tool that the Governor
talked about in his opening remarks that we use in primary care
offices, in emergency rooms, and in other healthcare delivery
sites in our State, it allows for the conversation to happen
with your healthcare provider or a healthcare provider where
you may become aware of your behavior to help you get there.
But, also, our Hub and Spoke model, the Hub is actually not
just a Hub for treatment. It is a Hub of activity where you can
go to receive counseling on your addiction and your options. We
also have recovery centers in the State where you can go to
basically reach out and get peer support for recovery.
So we have a lot of different doors you can open. We are in
the position now of how do we get more people into treatment,
because now we can meet the needs of treatment. The Governor
articulately went through our waiting list. We just recently in
the last 6 months have gotten to the point where we have
eliminated the waiting list. So now we are trying to figure out
how to get more people into treatment.
Mr. MARCHANT. Thank you.
Chairman ROSKAM. Mr. Blumenauer.
Mr. BLUMENAUER. Thank you very much for joining us. I
appreciate your efforts to kind of put a comprehensive picture
on the table for us, and I think each and every one of us on an
ongoing basis is struck by how complex and interdependent these
elements are in our own community.
We are troubled with addiction, homelessness, mental
illness, nothing rising probably to the level in terms of the
death and destruction of opioids, but there are a whole series
of interrelated pieces. And there is lots of blame to go
around: the Federal Government was asleep at the switch;
problems with the pharmaceutical industry; with the medical
profession.
And I appreciate your taking us through your outline of
what we could be doing. I was particularly struck by your
fourth point: Your small State could benefit tremendously from
nationally supported research for areas of alternative
treatment for pain. People are driven to opioids often when
there are, in fact, cheaper and more effective alternatives,
starting with therapy, but I would also point out one that my
State has been a pioneer in, and that happens to be medical
marijuana.
There is pretty strong evidence that where medical
marijuana is available, there are fewer opioid deaths. I think
in the State of California, it is a third less than the
national average.
And I have had countless people, veterans, tell me what a
difference it made for them to be able to have an alternative
that was cheaper, less toxic, they played--they felt more
comfortable with.
NFL players are suspended routinely, maybe not the wife
beaters, but the people who are caught self-medicating with pot
because they don't want to get shot up with painkillers, in
some cases leading to tragic, tragic consequences.
I am hopeful that this might be an area that we can
explore. You just became the first State to have the
legislature approve adult use of marijuana, something every
other State in the Union, 30 States, have done by a vote of the
people who have been ahead of the politicians on this.
And I wonder if you have some thoughts about opportunities
to use medical marijuana as an area to expand these treatment
options to be able to properly research it, to get rid of the
Federal prohibition on robust medical marijuana research and be
able to explore this as an alternative to this plague.
Governor SCOTT. We passed medical marijuana when I was in
the Senate, and I voted in favor and was one of the few
Republicans that did. I was serving with Congressman Welch at
the time.
We recognize that one size doesn't fit all, that that is
why we need as much flexibility as possible, all different
types of treatment on the table so to speak, so that we have
everything at our--in our power to confront this.
My wife is an RN. She lives this on a daily basis. She sees
it in the office on a daily basis, all the abuse in terms of
prescription drugs. But my wife is a runner as well, an
athlete. And she has had a number of knee surgeries. She
thought her running was over.
And she started using this oil therapy about a year and a
half ago, and she is back to running. She did a 10-miler about
2 months ago. So this works for her. My point is we just need
everything on the table. We can't allow ourselves to be--put
blinders on in terms of what might work for one that might not
work for another.
Chairman ROSKAM. Mrs. Black, another RN.
Mrs. BLACK. Yes, and thank you, Mr. Chairman.
And thank you to your wife who is an RN and a runner. So I
applaud you for tackling this issue that is a very large
problem.
And I want to go to the side, as you would expect an RN to
do, and that is, how can we stop this from happening to begin
with, because the cost of life, the cost of treatment, and the
cost of the illegal activity is certainly very, very large?
And so I am very interested in what you said in your
opening statement about the prevention piece of it and how your
State is using the prescription monitoring system to help
physicians. However, I do see in here, later on, you say that,
for the first time, we are beginning to see the amount of
opioid prescriptions decline. It is discouraging to note,
however, that we still prescribe three times as much as we did
in 1999.
So there is a little bit of a contrast there about having a
system where we can see what is going on, and yet there still
seems to be more of this being prescribed. Can you help me out
with that?
Governor SCOTT. Well, again, in 1999, it went--it
skyrocketed after that. There was just much more opioid
prescription use. So we have seen, since we implemented that
policy, we have seen it go down significantly. So--but still,
compared to 1999, we are still using three times as much.
Mrs. BLACK. So is this real time for your physicians that
they can get into a computer and see whether someone has a
prescription filled? And this is real time?
Governor SCOTT. Yeah, I believe it is. Yes, go ahead.
Mrs. BLACK. Okay. So that is very, very helpful.
Mr. GOBEILLE. So it is real time, yeah.
Mrs. BLACK. Okay. Let me go to the second piece, the early
intervention and the prevention piece, the screening, the brief
intervention referral to the treatment protocol, all of those
things that are done in the emergency rooms and primary care.
Is someone coming in that is self-referred, or is this
happening when they come in for other kinds of treatment that
the practitioner would say, ``Maybe this is something I need to
address,'' and talk about how is that actually done?
Governor SCOTT. I think it is all of the above, actually.
It could be from many different situations to at least make
others aware of the situation.
Mr. GOBEILLE. Yes. So the way we did this was we received a
grant and some Federal money to be able to do this in one
hospital, and we started there and we have kind of spread out.
And we don't do it everywhere in the State yet, but we do it
across a large part of--the majority of the State.
And it isn't just if you come in saying you think you have
an issue with addiction or substance use disorder. It is
literally if you come in for something else, we begin a
screening process that sort of--that begins the conversation.
And depending on how you answer questions and interactions, we
go further and further and further.
Mrs. BLACK. So you do the screening process on every
patient that comes in; they answer a screen, and then, from
there, you make a determination?
Mr. GOBEILLE. Right.
Mrs. BLACK. Okay. I had one additional question. In many
other States, we see doctor shopping. Have you seen that in
your State? Do you have pill mills? Do you see that doctor
shopping?
And do you also have those pain management facilities that
are for cash only? Are you experiencing that in your State?
Governor SCOTT. I don't think we see the pill mills in
Vermont, but certainly we see the doctor shopping, and some of
this electronic monitoring would help preclude that.
Mr. GOBEILLE. Yeah. So what is interesting is we don't have
what you think of as the traditional pill mill, but we
certainly had the issues you are describing. Doing the Spokes
and having over 200 primary care providers working together to
try to basically deal with treatment, it has been really good
for communication across the practice, and so it has cut down
on doctor shopping.
But also, our prescription monitoring system has improved
every year, and it is at the point now where doctors can see
that going on through software.
Mrs. BLACK. Thank you. My time is expired.
Thank you, Mr. Chairman.
Governor SCOTT. Keep in mind as well, if I could add--just
add----
Chairman ROSKAM. Wow, sliding into home. Nice.
Governor SCOTT. Keep in mind that if you shut someone off
from the prescription drug, the opioid, they find another
method. They go to heroin or fentanyl. I mean, it is cheaper
sometimes, so that is the problem.
Chairman ROSKAM. Mr. Higgins.
Mr. HIGGINS. Thank you, Mr. Chairman. And congratulations
as well on your ascension to the Subcommittee Chair.
My community, too, is devastated by the opioid deaths and
overdoses. There were 316 in Erie County in New York State.
Half of those were in the city of Buffalo. I just want to focus
in on fentanyl. Fentanyl is a--it is a powerful artificial
opioid, and it accounted for about 60 percent of the deaths in
my community of Buffalo and Erie County.
Mexico is a source of much of the illicit fentanyl that is
for sale in the United States. Starting in 2015, Canada has
seen a massive increase in fentanyl overdoses. You know, we are
currently engaged in a renegotiation of the North American Free
Trade Agreement.
And I have always believed that the United States and
Canada--the United States, a Nation of 323 million people,
Canada, a nation of 36 million people--doesn't effectively use
its leverage in trade negotiations with a place like Mexico.
You know, Mexico's minimum wage is $4.70, not an hour, a
day, which, if you assume it is an 8-hour day, is 57 cents an
hour. In free trade, we should be using our leverage to stop
this illicit transport, export of fentanyl to the United States
and Canada. It is a new twist on a larger problem. I am just
curious as to your thoughts about the viability of something
like that.
Governor SCOTT. Well, again, we watch with interest the
NAFTA negotiation. We share as well a border with Canada, and
they are our largest trading partner, essential to the vitality
of Vermont's economy.
So we are hopeful that we can get through some of those,
but I think that there should be an update to NAFTA, and I
believe that we should be trying to do whatever we can to level
the playing field, and that may be an area that we should look
at.
Mr. HIGGINS. Okay. The President in October declared that
the opioid epidemic was a national health emergency. As you
know, we have been kind of stuck in terms of doing a series of
continuing resolutions, which is really a failure to do
fundamentally what Congress needs to do.
But, obviously, money is a big issue here as it relates to
treatment. Have you seen any change, at least in terms of your
personal experiences, since that declaration was made in
October, or is that something prospective that just hasn't
gained traction yet?
Governor SCOTT. I don't believe we have seen any difference
since that declaration because we were--have been actively
pursuing that. And we have been blessed with having good
partners, again, with the Congress as well as with our--the
Administration and this previous Administration as well in
trying to confront this.
So we have--they have given us some flexibility, and I
think that has been essential. And if there is one thing that I
can underscore and emphasize it is this: Allow us flexibility,
and we will find the pathway forward.
Mr. HIGGINS. I yield back, Mr. Chairman. Thank you.
Chairman ROSKAM. Thank you.
Well, Governor, thank you, and, Mr. Secretary, thank you. I
just want to say thank you very much for your time today. We
are being called in for votes.
Let me ask you one wrapup question, if I could. Our
Subcommittee, and this Committee in particular, is focused on
Medicare. The first point that you made in your four points was
in particular as it relates to Medicare.
Let me just restate that part to refresh everybody's
recollection, and then I just want you to give us a little bit
of commentary about what this means. So what you have proposed
is Medicare needs to treat addiction as the chronic health
condition that it is.
And then you said you sent a letter to the Secretary of
Health and Human Services asking that CMS work with Vermont to
engage Medicare in Vermont's system of care, specifically the
Hub and Spoke system: Working with our Federal partners, we
hope to develop a path to make this a reality; Medicare could
also assure that the FDA-approved medications for opioid
addiction are available for beneficiaries.
I want to sort of go back to Mr. Marchant's inquiry when he
was asking about sort of the declaration of who is addicted.
Can you just give us a little bit more insight?
Is this a situation where, in order for this to be
successful at all, someone has to self-identify as an addict,
or does the Hub and Spoke system work for folks that are not
acknowledging themselves as addicts but who are clearly
addicts? Can you speak to that tension? Maybe it is a question
for the Secretary or medical professionals.
Governor SCOTT. Yeah, I am going to let him answer the rest
of the question, so to speak. But I would, again, underscore
that if they are not ready to admit they have an issue and to
seek treatment, it is probably going to fail. And so to force
someone into treatment is probably a recipe for failure as
well.
Secretary.
Mr. GOBEILLE. Yeah. So what I would say is there is a
definition of opioid use disorder, and, you know, they would
have to meet that clinical definition. And so, you know, that
is sort of the black-and-white answer.
But I think from a--you know, from a human perspective,
when you think about caring for the whole patient or the whole
population, to have something that is such a fundamental
problem with someone's health and not be able to treat it as
basically the illness that it is with the payer that they have
sort of distorts the healthcare system.
And so what we are trying to do is work with CMMI and CMS
to say we have an all-payer model that we have agreed to with
the Federal Government to really take responsibility for what
we spend on healthcare. And in order to do that, you have to
treat the whole person and the whole population, and this needs
to be an integral part of that.
Governor SCOTT. And if you want to break down the stigma,
this is one way to do it, to treat them the same.
Chairman ROSKAM. Well, your insights have been really
helpful today. And you didn't clear the room, by the way. You
didn't clear the dais; it was the fact that we have been called
for a vote.
But I just want to let you know how much I appreciate--and
I know I speak on behalf of the Ranking Member as well--your
willingness to come and share your experience. We appreciate
your forthrightness with the strengths and weaknesses, the
things that you have learned, and the things that you have
struggled with.
And I know that we are going to continue to be interacting
on this issue because this is a problem that is very dear to
all of us, and I mean literally all of us. And it is an area
where there is good work that can be done. And I think people
of good will and tenacity willing to give others the benefit of
the doubt as we move forward can be really, really significant.
So I sense you have something else to say, Governor, so why
don't you respond?
Governor SCOTT. Well, I only wanted to say that we extend
an invitation to anyone on your Subcommittee who would like to
come up and see it for themselves. We would happily show them
what we have done so that they can see it.
Chairman ROSKAM. Thank you.
So the Committee stands in recess subject to the call of
the Chair. We are going to go into recess and vote, and we will
look forward to hearing from our next panel.
So thank you very much. We will be back shortly.
[Recess.]
Chairman ROSKAM. The Committee will come to order. Thank
you, all. I know I speak on behalf of everybody who is
reassembling here and thank you for your patience.
As I mentioned, your opening statements are a part of the
record, and the Members have had an opportunity to review them.
I think that in the interest of time, why don't we begin to
proceed. I will recognize each of you for 5 minutes, and we
will give you a little bit of guidance in terms of the timing,
and then we will open it up for questions from our Members.
So, again, thank you for your patience. We really, really
appreciate it. Dr. Benyamin, you are recognized for 5 minutes.
STATEMENT OF RAMSIN M. BENYAMIN, M.D., PRESIDENT AND FOUNDER,
MILLENNIUM PAIN CENTER, AND BOARD OF DIRECTORS, AMERICAN BOARD
OF INTERVENTIONAL PAIN PHYSICIANS
Dr. BENYAMIN. Chairman Roskam, Ranking Member Levin, and
distinguished Members of the Committee, thank you for the
opportunity to provide my views on behalf of American Society
of Interventional Pain Physicians, known as ASIPP.
I am Dr. Ramsin Benyamin, and I am the Medical Director of
Millennium Pain Center in Illinois. I have been practicing
interventional pain management for over 20 years. My academic
appointments are with the University of Illinois, Illinois
Wesleyan University, and A.T. Still University of Missouri.
I serve on the editorial board of several pain management
peer-reviewed journals and have over 150 publications, the most
recent of which is our society's 2017 guidelines for
responsible, safe, and effective prescription of opioids.
In the past, I have served as the President of ASIPP, and I
am currently on the board of directors. I am also the President
of Illinois' Society of Interventional Pain Physicians.
ASIPP is a not-for-profit professional organization founded
in 1998, now comprising over 4,500 members who are dedicated to
ensuring safe and appropriate access to pain management
services using interventional techniques in addition to medical
management.
As an organization, ASIPP has always been cognizant of
prescription opioid dangers and began issuing warnings and
offering preventive measures in early 2000 with its proposal of
a national program known as NASPER, which eventually was signed
into law as a State-run prescription drug monitoring program in
2005.
Despite challenges in implementation of the national
program, all 50 States now have prescription drug monitoring
programs. Many of the common painful ailments, like spine
degeneration, disk herniations, spinal stenosis, headache,
pathologic fractures, and postsurgical chronic pain, if not
managed timely by interventional pain techniques, would result
in more invasive and costly procedures, raising the risk of
dependency on more or higher doses of opioids.
Currently, one in every three Medicare Part D recipients is
on prescription opioids. Based on current data, despite
reduction in opioid prescriptions since 2010, the majority of
overdose deaths are mainly due to synthetic fentanyl and heroin
abuse.
Mr. Chairman, the pill-to-heroin shift has occurred, and
that also involves lacing of marijuana with heroin or fentanyl.
That is killing many of my fellow citizens in Illinois.
As a result of this disturbing trend, on behalf of ASIPP, I
am suggesting legislative reforms to curb opioid abuse and
reduce opioid deaths while maintaining appropriate access and
promoting nonopioid modalities like interventional techniques.
Unfortunately, reductions and cuts continue to limit access
to physical therapy, interventional techniques, and even
nonopioid medical therapies while the opioid death rate
continues to escalate.
Our proposal includes a three-tier approach. Tier one: An
aggressive public education campaign focused on the dangers of
illicit drugs, specifically heroin and fentanyl; a public
education campaign relating to the adverse consequences of
prescription opioid abuse, particularly in combination with
benzodiazepines; and a mandatory 4 hours of continuing
education for all prescribers of any amount of opioids or
benzodiazepines.
Tier two: Improved access to nonopioid techniques,
including physical therapy and interventional techniques, by
lowering or eliminating copayments; expanded low-threshold
access to buprenorphine for opioid use disorder treatment;
enhanced prescription drug monitoring program, including a
national program like NASPER, which States having mandated
capability to interact with the rest of the States or at least
the neighboring States; and mandated review of prescription
drug monitoring data by all prescribers prior to prescribing a
controlled substance.
Tier three: Buprenorphine must be available for chronic
pain management with rescheduling it to a schedule two; and
removing methadone from formulary. This medication, despite
being only 1 percent of total prescription opioids, results in
more than 3,000 deaths every year.
Thank you, again, for allowing our organization the
opportunity to testify. I will be glad to answer any questions.
[The prepared statement of Dr. Benyamin follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman ROSKAM. Thank you.
Mr. Kletter.
STATEMENT OF JASON KLETTER, PH.D., PRESIDENT, BAYMARK HEALTH
SERVICES AND BAY AREA ADDICTION RESEARCH AND TREATMENT (BAART)
Mr. KLETTER. Chairman Roskam, Ranking Member Levin, and
Members of the Subcommittee, I appreciate the opportunity to
testify today about the opioid epidemic that is ravaging our
country and important steps this Committee can take to help
address this crisis.
I am Dr. Jason Kletter, President of BayMark Health
Services. BayMark provides treatment for opioid use disorder,
or OUD, using medication-assisted treatment and outpatient
detoxification services in 95 facilities across 26 States,
including many of the States you represent. We are the largest
organization in the country focused primarily on treatment
services for opioid use disorder treating over 33,000 patients
each day.
I also serve on the Board of the American Association for
the Treatment of Opioid Dependence, and I am also here today on
behalf of the OTP consortium, a trade association comprised of
more than 300 opioid treatment programs across 37 States. I
have 25 years of experience in OUD treatment.
I want to start by highlighting two data points: First,
according to the CDC, opioids killed more than 42,000 people in
2016. That is about 115 people every day in our country. These
are our friends, our family, our neighbors, our coworkers.
Second, the White House Council of Economic Advisers
estimates the economic cost of the opioid crisis was $504
billion in 2015 alone. Of course, these statistics do nothing
to describe the devastating effects on our families and
communities.
OUD is regarded by experts to be a disease of the brain,
not a moral downfall. This concept of OUD as a chronic disease
is essential to understanding successful treatment solutions,
the most effective of which is medication-assisted treatment.
MAT is the integration of medication and psychosocial
services to provide individualized care that will have the
greatest likelihood of helping people with OUD transition to
recovery and lead healthy, socially productive lives.
There are three federally approved medications for use as
part of MAT, methadone, buprenorphine, and naltrexone, all of
which must be used in conjunction with psychosocial services to
have the greatest likelihood of success.
The benefits of MAT are substantial and have been proven
repeatedly through rigorous scientific studies. MAT has been
shown to improve patient survival, increase retention in
treatment, decrease opioid use and criminal activity, increase
patient's ability to gain and maintain employment, and lower
person's risk of contracting HIV or hepatitis C.
Those who receive MAT are 75 percent less likely to have an
addiction-related death than those who don't. There are roughly
1,500 opioid treatment programs, or OTPs,
across the United States providing treatment to approximately
400,000 patients. OTPs are highly regulated, comprehensive
treatment programs that are required by law to provide MAT.
OTPs provide medication, individual and group counseling,
random drug testing, and other supportive services, such as
case management, primary care, mental health services, HIV, and
hepatitis C testing.
Methadone, which is most commonly administered as part of
MAT, has been used in OTPs for more than 50 years. It has been
rigorously researched and considered to be the gold standard in
treatment of opioid dependence. MAT with methadone is highly
regulated and can only be dispensed for OUD by clinics that
have been certified by SAMHSA, the DEA, and other agencies. It
is an excellent medication when used as part of MAT with
patients having very high retention and success rates.
Retention in treatment over an extended period of time is
essential for positive outcomes. At BayMark, about 61 percent
of our patients are retained in treatment for at least 90 days.
Furthermore, while 100 percent of our patients are using
opioids multiple times each day upon admission, about 50
percent of those folks in treatment less than 30 days are free
from illicit opioids. That number jumps to 82 percent for
patients in treatment more than 1 year. This is proof that MAT
delivered in OTPs is saving hundreds of thousands of lives.
According to CMS, 30 percent of Part D enrollees used
prescription opioids in 2015. So we should not be surprised
that more than 300,000 Medicare beneficiaries have been
diagnosed with opioid use disorder. Moreover, Medicare
beneficiaries have the highest and fastest growing rate of OUD.
Unfortunately, Medicare does not cover comprehensive
treatment services in OTPs. Instead, Medicare pays for more
expensive treatments in less effective settings. This must
change.
We respectfully request that Congress pass legislation to
pro-
vide Medicare beneficiaries with coverage for MAT with all FDA-
approved medications to help treat OUD in the OTP setting. We
recommend that Medicare adopt a bundled payment methodology
where MAT-related services provided in the OTP setting are
reimbursed under a capitated rate. This model has proven to be
successful in Medicaid and TRICARE and could be quickly
implemented by the 1,500 OTPs across the country, rapidly
increasing access to lifesaving treatment for Medicare
beneficiaries.
While our country is in the throes of a tragic epidemic,
the silver lining here is that we have a very effective
treatment and a dedicated and compassionate workforce ready and
able to save lives and build communities.
Thank you for the opportunity to testify today. I am happy
to answer any questions that you have.
[The prepared statement of Mr. Kletter follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman ROSKAM. Thank you very much.
Dr. Paz.
STATEMENT OF HAROLD L. PAZ, M.D., M.S., EXECUTIVE VICE
PRESIDENT AND CHIEF MEDICAL OFFICER, AETNA, INC.
Dr. PAZ. Thank you, Chairman Roskam, Ranking Member Levin,
and Members of the Subcommittee, for holding today's hearing on
the opioid abuse epidemic. I appreciate the opportunity to
share Aetna's perspective on this critical public health issue.
Aetna is a leading diversified health company that serves
over 38 million individuals in the United States and around the
world. I currently serve as the company's Executive Vice
President and Chief Medical Officer, a role I have held since
2014.
In my capacity as CMO, I lead clinical strategy and policy
across Aetna's lines of business and am responsible for driving
clinical innovation to improve member experience, quality, and
cost. I am also a practicing physician.
The opioid epidemic is the leading public health issue
facing our Nation. We have already lost far too many of our
friends, family, and neighbors to this unprecedented health
crisis. Aetna is taking a holistic approach to addressing the
opioid epidemic.
The various segments of Aetna's businesses are all working
to help our members struggling with addiction and to prevent
future opioid dependency. To that end, Aetna has created an
enterprisewide opioid task force, which I chair, to drive a
multifaceted strategy to help stem the tide of overuse.
We have developed a strategy focused on preventing misuse
and abuse, intervening when we identify at-risk provider and
member behavior, and supporting members by providing access to
evidence-based treatments.
I am pleased to share with this Subcommittee three examples
of Aetna's efforts to fight the opioid epidemic as well as
recommendations for Congress and the Administration. We believe
important efforts in our commercial lines of business can
inform how CMS regulates Medicare Advantage and Part D plans to
allow for similar programs in the Medicare space.
First, within our commercial business, Aetna is leveraging
formulary and plan design tools, such as quantity limits and
prior authorization, to reduce opioid misuse and encourage
evidence-based treatments.
For example, as of January 1, Aetna is limiting initial
opioid prescriptions for acute pain to a 7-day supply. These
stricter daily and dosage limits are in alignment with CDC
guidelines and will help to reduce the potential for abuse and
addiction.
Second, effective January 1, Aetna became the first and
only national payer to waive copays for Narcan, a lifesaving,
highly effective opioid overdose reversal agent, for our fully
insured commercial members once their deductible is met. We
hope this copay waiver will increase access to remove possible
financial barriers to the use of naloxone.
Third, within Aetna's Medicare business, we are striving to
be part of the solution. Aetna has taken steps to promote
appropriate prescribing and coordination of care for our
Medicare members who utilize opiate drug therapies.
Aetna has instituted interventions in its Medicare
formularies to assist members in receiving appropriate opioid
medication when necessary while preventing inappropriate use
and addiction. We also support pharmacists in utilizing opioid
controls as well.
Aetna is committed to continuing to work with CMS to
highlight areas of opportunity for change to better combat the
opioid epidemic. We believe there are three specific areas
where Congress and CMS can take additional steps to help remove
barriers currently limiting the ability of plans to combat the
epidemic itself.
First, while Aetna now limits initial fills of acute opioid
prescriptions to a 7-day supply in our commercial business,
Medicare Advantage and Part D plans are precluded from
unilaterally limiting the duration of a prescription. We are
encouraged that CMS in its recently released call letter is
proposing significant steps to allow Medicare and Part D plans
to take more action to preventing over prescribing.
We strongly encourage CMS to finalize provisions that allow
additional point-of-sale edits and supply limits of
prescription opioids that limit initial prescribing to a 7-day
supply.
Second, we also support CMS' continued efforts to address
the opioid epidemic and believe the implementation of CARA and
the adoption in Part D of a lock-in mechanism will prevent
sponsors with a critical tool to help--will provide sponsors--
excuse me--with a critical tool to help curtail the abuse of
opioids.
Still, we believe there are several changes CMS should make
in implementing the lock-in program to ensure its success, such
as allowing Part D sponsors to retain the ability to use point-
of-sale claim edits to address other frequently abused drugs
and allowing plans to maintain the lock-in status of a member
until notified by the applicable provider that the member is no
longer at risk.
And, finally, we strongly support modernizing privacy
regulations to provide access to a patient's entire medical
record, including substance use disorder records, and to ensure
that providers and organizations have all the necessary
information to provide safe, effective, high-quality treatment
and care.
We urge Congress to expeditiously pass the bipartisan
legislation introduced in the Senate and here in the House by
Representatives Mullin and Blumenauer to align this outdated
regulation with already strict HIPAA standards.
In conclusion, Aetna is deeply committed to doing its part
to turn the tide on the epidemic. We look forward to continuing
to play a productive role in the dialogue with the Subcommittee
and with other policymakers to help find solutions to this
epidemic.
Thank you, again, for your leadership on this issue and for
inviting Aetna to be here today.
[The prepared statement of Dr. Paz follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman ROSKAM. Thank you very much.
Ms. Hungiville.
STATEMENT OF LAURA HUNGIVILLE, PHARMD, CHIEF PHARMACY OFFICER,
WELLCARE HEALTH PLANS, INC.
Ms. HUNGIVILLE. Mr. Chairman, Ranking Member Levin, Members
of the Committee, I am Laura Hungiville, Chief Pharmacy Officer
for WellCare Health Plans. I want to thank you for your
invitation to appear today to share with you our experiences
regarding the opioid epidemic and the variety of practices we
have employed aimed at curbing the overuse and misuse of
prescription opiates.
It is important that the Committee is addressing this vital
issue, and managed healthcare companies are equally committed
to finding solutions. First, though, let me tell you a little
bit about WellCare. Headquartered in Tampa, Florida, WellCare
focuses exclusively on provider government-sponsored managed
healthcare services through Medicaid, Medicare Advantage, and
Medicare prescription drug plans.
WellCare prides itself on managing healthcare services for
the underserved and most vulnerable populations. We serve 4.3
million members nationwide with roughly 1 million members
relying on WellCare for prescription drug services.
In any given State our beneficiary population ranges from
40 to 50 percent dual eligible. While certainly not the only
population at high risk of controlled substance misuse, mental
illness and poverty often go hand in hand with substance abuse
disorders.
We have spent the last several years investing resources
and time into innovative methods for decreasing the misuse of
controlled substances among our beneficiaries, culminating most
recently in the launch of an opioid task force.
This task force was created to ensure that we are taking an
integrated approach to helping our members. Our company has in-
sourced medical, pharmacy, and behavioral departments, a rarity
among managed care plans, to ensure that we are looking at the
member in a holistic manner.
First and foremost, our goal is to prevent abuse and
addiction. Our second goal is to help our members who are
battling addiction and often chronic pain to help them manage
both conditions. Those members who are at the greatest risk of
overdose and death receive the highest attention.
One of our key programs involves monitoring doctor and
pharmacy shopping so we can flag high utilizers. WellCare works
with patients to enter into medical service agreements, which
patients benefit from having a single doctor focused on
prolonged pain management therapies to deter opioid misuse.
For several years, WellCare's pharmacy-run opioid
overutilization case management program has been using
predictive modeling to identify at-risk individuals. As a
result, WellCare proactively identified over 200 at-risk
members nationally in 2017 based on specific criteria,
including prescription dispensing, provider, and emergency
department utilization.
We placed these individuals into a lock-in program
connected to one pharmacy, one healthcare provider, and a care
manager who helps connect members to needed physical,
behavioral, pharmacy, and social services.
In regard to the CMS standard for morphine-equivalent
dosage, we have also identified 2,100 additional members who
have received prescriptions over the previous CMS standard of
120 milligrams of opioids per day. We intervene with these
members through member education on alternative medications,
outreach to prescribers, and have begun including integration
point with our behavioral health case management team. For our
noncancer members, this translated into utilization reduction
of over 43 percent between 2015 and 2017.
Since the transition to the lower daily ceiling of 90
milligrams of morphine-equivalent doses, WellCare continues to
see increased numbers of members captured through our
overutilization case management program.
We also recognize that we must look beyond the treatment of
pain to address opioid overuse. Our multifaceted set of
interventions includes the creation of the CDC-compliant task
force and engaging policy groups at the State level to include
prescription drug monitoring program training, and CME for
physicians on the training of using opiates.
Some of these partnerships also include working with the
YMCA to educate teens on the risk of opioid use, especially in
the foster care system. At the organizational level, we are
rolling out telehealth programs for use in emergency rooms to
help increase medication-assisted treatment.
And, finally, we are also developing incentive programs for
physicians to become SAMHSA certified, given the increased
demand for addiction specialists.
Much of which I have outlined has been possible because of
States like Kentucky where Medicaid regulations allowed us to
be aggressive in targeting opioid misuse. In Kentucky, we are
able to see a decrease of nearly 50 percent.
We would also like to recommend CMS incentivize other
providers to become SAMHSA certified, allow health plans to be
empowered to have more restrictive lock-in programs, mandate
electronic prescribing of opioids, and address the gaps that
create barriers for plans by providing PDP plans with access to
medical claims, and allow health plans access to PDMPs as well.
Lastly, Congress, CMS, and the FDA should create
educational campaigns similar to the one deployed for tobacco
cessation to educate consumers about the dangers of the opioids
and remove the stigmatization and encourage people to seek
help.
In conclusion, ending this opioid crisis will require a
partnership with all stakeholders, and WellCare looks forward
to being an active participant as the Committee and Congress
work to combat this epidemic. Thank you.
[The prepared statement of Ms. Hungiville follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman ROSKAM. Thank you very much. You have given us
great insight and very valuable perspectives.
We are in a very uncertain time right now in terms of
scheduling and the chatter that we are getting about being
called back in. Since this has been a two-panel hearing today,
I would ask unanimous consent to limit the Members' questions
to 3 minutes.
And, without objection, so ordered.
And, with that, we will yield to recognize Mr. Kelly.
Mr. KELLY. Thank you, Mr. Chairman.
Thank you all for being here.
Dr. Benyamin, I was fascinated by your testimony. And I
think last year when President Trump talked about this war on
drugs, he had talked about nonaddictive painkillers because we
are a Nation now of dependence or codependence. I don't think
there is any doubt about that.
If you could just go a little bit further into that. I
marvel at the fact that we have 50 laboratories around this
country that are collecting all this type of data. But your
testimony, more than anything, appealed to me because I have
been so close to this issue.
Would you expand a little bit more on the fact that we do
have a way of keeping pain down? But I think the development of
those drugs also had to do with reimbursements, right? If we
can keep the pain down and the patient says, ``I am not feeling
the pain,'' it is a better result. But it involves an
addiction. So please hit the nonaddictive ways of killing pain.
Dr. BENYAMIN. Thank you, Congressman. That's a very good
question.
We can divide that into two sections, the medication part
and
the interventional part. So, on the medication front, we have
had challenges as far as funding and research funding for
nonad-
dictive medication, as you know. And we do not have many
choices.
Our choices are between scheduled prescription drugs and anti-
inflammatories. And we all know that anti-inflammatories have
their own side effects.
One of the issues is access. Many of the health plans do
not cover nonopioid medications. Like, I will give you a good
example of a patch that is anti-inflammatory. If you call for a
preauthorization, unanimously, they all will deny the patch.
They will say to you: Well, we do not cover the anti-
inflammatory patch, but we do cover the fentanyl patch. That is
the answer that you get. So that tells you part of the problem
that we face.
On the nonmedication front, I think we are a young
specialty. Interventional pain management is a young specialty.
And we have been adding to our tools to treat, as I mentioned,
the spinal disorders, like spinal stenosis, and fractures in
the spine. These are conditions that, in the past, we did not
have any solution for between surgery and opioids. And now we
are providing solutions that are minimally invasive techniques
that can prevent these patients from getting to the point of
becoming dependent on opioids or having all these invasive
surgeries and, as a result, becoming dependent on opioids.
Mr. KELLY. Sir, I want to thank you. I am running out of
time. I want to thank you all for being here. We have run out
of options as a country. We have to get this fixed. So thank
you so much for what you are doing. Please continue your work.
We really appreciate you being here. Thanks so much.
I yield back, Mr. Chairman.
Chairman ROSKAM. Mr. Levin.
Mr. LEVIN. Well, I join in our appreciation for all of your
efforts.
Just quickly--and then I wanted to ask you another
question--why do you think it took us so long to recognize this
epidemic? Anybody want to venture? It did take us a long time.
Dr. BENYAMIN. Can I take a shot at that?
Mr. LEVIN. Please.
Dr. BENYAMIN. So I think part of it is a lack of awareness
and a lack of knowledge, a lack of public information, and
usually we react. You know, we always react, we go from one
extreme to the other.
As I said before, this is not just a pill problem anymore.
The shift has occurred from the pill to heroin and synthetic
fentanyl. And I will be glad if we take some precautionary
legislation that will prevent that from happening and reduce
the supply of these drugs in our country.
In my community, the rate of death from opioid overdose had
tripled in 3 years. And, you know, I would like you to
understand that it is very hard for the coroner to determine
the exact cause of death. You know, all these data are based on
coroners' reports, which is based on what pathologists find in
the system.
Now, if you have five, six, seven medications or drugs in
the system, who is to say which one of these is the real cause
of death? That is why they mark them all as opioid overdose.
Mr. LEVIN. So let me ask you then, in terms of awareness,
expanding Medicare treatment, isn't that a very good idea,
Doctor?
Mr. KLETTER. So, if I could add to that, I think, to your
first question, the reason it has taken so long to recognize is
less about not recognizing it and more about the stigma
associated with the disease.
People with the disease of addiction are sort of shunned
and kept in the shadows and embarrassed and shamed, and
treatment has been sort of similarly treated. There hasn't been
a lot of attention or focus on treatment services. In fact,
physicians are not taught how to treat addiction in medical
school generally. They are not taught a lot about opioids and/
or addiction.
Mr. LEVIN. So expanding Medicare----
Mr. KLETTER. So how can expanding Medicare help? Well,
first of all, making it part of mainstream medicine, helping to
sort of acknowledge the disease as just that, as a disease.
We heard Governor Scott of Vermont earlier say we need to
do a better job of making--of acknowledging the disease and
thinking of it as a disease rather than thinking of it as a
lack of will power or a moral downfall.
Mr. LEVIN. Okay. So----
Mr. KLETTER. And so Medicare contributes to that by, you
know, legitimizing the treatment that we have as a medical
treatment.
Mr. LEVIN. Thank you.
Chairman ROSKAM. Mr. Paulsen.
Mr. PAULSEN. Thank you, Mr. Chairman.
I want to follow up a little bit on some of the
perspectives that were offered on the minimally invasive
procedures. And, look, I mean, historically, the practice of
providers has been to prescribe opioids to patients for years,
and it is hard to stray away from that course and then to try
new different therapies for pain management.
Now, I also understand that there are about 200 FDA-
approved devices for which CMS does reimburse, but it seems
that not enough providers or Medicare Advantage plans, for
instance, are alerting patients to some very effective and
efficient ways to manage pain outside of the risk of addiction.
One example is a spinal cord stimulator that involves a
minimally invasive procedure and uses electrical signals to
block pain signals from reaching the person's brain. It has
about a 50 percent or greater opportunity for reduction in
pain, and more than half of the patients don't need to have any
pain medication for that management. And it is FDA-approved. It
is Medicare reimbursed. It has helped about 500,000 patients.
So I am just curious, maybe Dr. Paz and Ms. Hungiville
first, what are your health plans doing in general to ensure
that providers are aware and that patients have access to some
of these covered nonopioid treatments?
Dr. PAZ. So thank you very much for the question.
So we, as you indicated, cover these types of devices for
patients that appropriately fit the criteria. And where we
spend a great deal of our emphasis at our opioid-wide task
force is really looking at patients with acute pain because
that becomes the entry point for them being exposed to opioids
in the first place. And that is where alternative types of--my
colleagues mentioned, alternative types of treatment come into
play, physical therapy, chiropractic, osteopathic, manipulative
therapy, different types of approaches, the use of
nonsteroidals, SSRIs, for example. These are things that we can
do for acute pain. And, frankly, there is data that shows that
some of the over-the-counter treatments of pain, acetaminophen
even, nonsteroidals, can be equally effective, if not more so,
for the treatment of those situations.
When a patient has long-term chronic pain, that is a
different matter altogether. And, quite frankly, in those
situations, if we think it is appropriate, we will cover
opioids because that may be the only treatment that is
effective. But, certainly, also if a physician is recommending
or prescribing a device, that is something that would be
covered as well.
Mr. PAULSEN. Ms. Hungiville, are there any barriers to
nonpharmaceutical therapies for chronic pain that currently
exist, or can you expand on----
Ms. HUNGIVILLE. It is awareness, and through our case
management, we are trying to educate providers as well as our
beneficiaries that there are alternatives to the opioid
treatment. And so that is one of the interventions that we
employ: to make them aware of other alternatives.
Mr. PAULSEN. Good. I mean, this seems to absolutely make
sense based on the testimony we are hearing. So I appreciate
your perspectives and yield back, Mr. Chairman.
Chairman ROSKAM. Mr. Reed.
Mr. REED. Well, thank you, Mr. Chairman.
And the question I have is for Dr. Benyamin. I am sorry. Is
that it?
Dr. BENYAMIN. Benyamin.
Mr. REED. Oh, okay. Thank you. I appreciate that, Doctor.
The question I have for you is, pain, in and of itself, is
that a bad thing, from a physician's perspective?
Dr. BENYAMIN. It depends on the condition. If it is acute,
it is always an alarming sign that there is something
happening.
Mr. REED. So as a physician--and I see two doctors up
there--what is a successful outcome of pain management? Is it
zero pain? Or is there some level of pain that to me is a
natural response of the body telling a doctor, ``Hey, there is
an issue here''? And are doctors and physicians trained to
overmedicate in order to get to an unlikely outcome of zero
pain, which is probably not, in my humble opinion, the best
outcome that we can anticipate from physicians?
Dr. BENYAMIN. Absolutely, Congressman.
Mr. REED. So could you explain that a little bit?
Dr. BENYAMIN. Yeah. This is how we--part of the reason why
we got into this crisis is in all these regulations that we had
by the hospitals. If you remember, there was a time they used
to call pain the fifth vital sign.
Mr. REED. Uh-huh.
Dr. BENYAMIN. I mean, it cannot be ignored.
Mr. REED. Where do those regulations come from? Government,
right?
Dr. BENYAMIN. From government, right.
Mr. REED. We directed you to get to zero pain, did we not?
Dr. BENYAMIN. Right. So that was enforced in the hospitals.
All the accredited institutions, health institutions, needed to
address--assess and address pain to a point that the pain level
will go down to anywhere below four.
Now, as you know, that is a very subjective number. And if
you look at Medicare actually, they never talk about
regulations. They usually talk about--they never talk about the
numbers. They talk about quality and function of the patient.
So I think we need to shift this emphasis toward quality of
life and function, and those are the tools that we use in our
practice. And we rely much less on that number unless it is
required by a lot of insurance companies.
I will give you an example. The Congressman mentioned the
spinal cord stimulator. We have this arbitrary number of 50
percent. If the patient's pain didn't go from 8 to 4, well,
then, his implant will not be approved, right?
Mr. REED. So, as we learn from that experience going
forward and setting policies going forward, could you provide
me some insight as to how we would do the new regulations to
encourage a better outcome than what we may have, by unintended
consequences, made in good faith to limit pain but had an
unintended consequence of exacerbating this problem?
Dr. BENYAMIN. Absolutely, unintended consequences. That is
what we are facing. And that is why I was mentioning to the
Chairman that we need to--if we are looking for a solution,
there is no one magic wand that we are going to wave here and
solve this problem. This has many aspects to it.
As the Governor mentioned, I like that four pillars of the
treatment on--how to address this issue. And you have to work
at the prevention. You have to work on recognizing, what is the
disease? Is the patient having a substance use disorder? Treat
that, treat the consequences, prevent disasters, and limit the
supply. If you look--or, you know, the studies have shown that
when you limit the supply, we have less of a prescription
writing and less deaths.
Mr. REED. Thank you very much for the input.
Chairman ROSKAM. Mr. Renacci.
Mr. RENACCI. Thank you, Mr. Chairman.
It is interesting what my colleague, Mr. Reed, mentioned,
because I was 18 years old in a horrible motorcycle accident
and went to school the next day with a bottle of aspirin. It is
amazing how government has changed things.
But, anyway, I have introduced legislation with Congressman
Mark Meadows that would enact a 7-day limit on opioid
prescriptions for acute pain with some exceptions. It was
crafted in consultation with over 30 stakeholders to address
what studies and researchers have proven time and time again:
risk of addiction increases with the length of your opioid
prescription.
Dr. Paz, in your testimony, you state that Aetna limits
opioid prescribing for acute pain to a 7-day supply. CMS has
recently proposed limiting initial limit fills to 7 days. This
would apply for all new opioid users in Medicare as well as
require plans to implement a hard edit for beneficiaries
prescribed more than a 7-day supply of opioids.
Dr. Paz, what research led to Aetna's decision to adopt a
stricter threshold before Medicare proposed it?
Dr. PAZ. So this is in our commercial plans, and we base
that on the CDC recommendations. Those are the same
recommendations that we share with physician and dental
superprescribers, who are prescribing large quantities of
opioids to our members as well.
We think that is very important guidance. It is something
that should be used by the provider community, by physicians
and dentists who have prescribing privileges. And we felt the
first place to put that in place was in our commercial plans
where we could, in fact, do that.
Mr. RENACCI. So do you believe limiting opioid
prescriptions for populations other than Medicare
beneficiaries--I think you have said this--would have an effect
similar to what CMS is hoping to achieve with Medicare
beneficiaries?
Dr. PAZ. So I would say that there is one exception to
that, Congressman, and that is in individuals that are not
suffering from acute pain but in individuals that are
terminally ill with cancer, for example, in hospice. There are
circumstances where there are very good reasons to have long-
term use of opioids. But we are focused here, and most of the
situations we are looking at are, in fact, really 35 percent of
the population are coming to us with acute pain situations.
Mr. RENACCI. Well, it is interesting. My bill provides
exceptions for cancer treatment, hospice care, palliative care,
and chronic pain.
The next question is for any of the witnesses: What
exceptions would you all recommend for CMS as well as what
should Congress consider as a nationwide prescription limit
other than those four? You mentioned those. Are there any other
exceptions that anyone on the panel thinks we should have?
Okay. I yield back.
Chairman ROSKAM. Mr. Thompson.
Mr. THOMPSON. Thank you, Mr. Chairman.
Dr. Kletter, you heard about the Hub and Spoke program, a
program with the Spokes. What can we do or do better at the
Federal level to enable the success of this program rather than
to impede it?
And I have a county that I represent, Lake County, which is
contiguous to your second home, that has a high opioid--a
terribly high opioid problem. And what can we do to make sure
that they have long-term access to these services, and can you
talk a little bit about the barriers in the Medicare program
that would prevent treating those patients?
Mr. KLETTER. Sure. So we heard quite a bit about the Hub
and Spoke program from Governor Scott. It is a fantastic
program. BayMark happens to operate three of the six Hubs in
the State of Vermont, so we are very fond of it. And we are
developing 4 of the 19 in California.
While Vermont is a very small State, they have created what
seems to be a no-brainer. This is one of the most effective
approaches to treating the opioid epidemic we have seen in the
treatment community.
So what can Congress do? Well, as I said in my testimony,
Congress can pass legislation that would allow Medicare to
cover treatment services at OTPs. OTPs are the Hubs within this
Hub and Spoke program. And the concept is that you get a Hub
where all three federally approved medications can be provided
and wraparound services, including counseling and drug testing,
and other supportive services are provided.
And then patients are admitted at the Hub, they are
stabilized there, and then once they are stabilized, they are
stepped down to a less-restrictive model of care, level of
care, and those are the spokes. Those are primary care
physicians generally.
And the reason that the model was created was because, as
we know, many primary care physicians have been reticent to
prescribe medications to folks with opioid use disorder because
it is a complicated disease and requires a lot of attention.
The beauty of the Hub and Spoke system is that the Hub
provides services in the form of a MAT team, a nurse, and a
counselor, to the Spoke so that the physician has additional
resources in dealing with the patients, in helping the patients
manage their medications, making sure they are not being
diverted, making sure they are taking them on time, making sure
they are participating in all the services, like counseling,
that are required for effective outcomes.
So coverage in Medicare is important, and we work quite a
bit with SAMHSA, who has been helpful in developing more OTPs
around the country. The CURES funding that came out of Congress
last year or this year has been used in California primarily
for developing this Hub and Spoke model. It is being used in
other States to develop the Hub and Spoke model.
So we would encourage you to look very closely at how
States are using their CURES funding and make sure that they
are using it in ways that are evidence-based and are, in fact,
intervening in this epidemic and reducing overdose deaths.
Mr. THOMPSON. Thank you. I yield back.
Chairman ROSKAM. Ms. Jenkins.
Ms. JENKINS. Thank you, Mr. Chairman.
And thank you all for being here today.
I have introduced a piece of bipartisan legislation called
the Furthering Access to Coordinated Treatment for Seniors Act,
or the FACTS Act, which helps to bridge the gap in
communication between the clinical setting, where patients are
diagnosed and prescribed medication, and the pharmacy setting,
where patients receive their medications. In particular, for
opioids, having information about hospitalizations due to
medication mismanagement can add in another layer of support
from the Part D and pharmacy community. This coordination is
something that is desperately needed in fee-for-service
Medicare, and I really look forward to advancing it here in the
House.
With that said, Ms. Hungiville, as I understand, standalone
Part D plans cannot review Part A and B claims data. Is that
correct?
Ms. HUNGIVILLE. That is correct.
Ms. JENKINS. And Medicare Advantage prescription drug plans
can review A and B data plans. What type of challenge does this
lack of data present for standalone Part D plans in managing
the benefit of a potential opioid abuser, and what could plans
do to assist beneficiaries in claims if data were made
available?
Ms. HUNGIVILLE. Well, we are limited to identifying those
members that are at the greatest risk. For the members in our
Medicare Advantage plan, we are looking at their prescription
utilization. We are looking at their hospitalizations. We are
looking at their ER visits. And we are predicting, sometimes
with their first opioid prescription, whether they are at risk
for developing into addiction, and we are putting them into our
treatment algorithms.
In our standalone Part D plan, we don't have that
visibility. So we have to rely on the traditional multiple
prescriptions from multiple pharmacies and multiple providers.
So we are not able to intervene as quickly as what we would
like and hopefully prevent addiction rather than treating
addiction.
Ms. JENKINS. Okay.
Thank you, Mr. Chairman. I yield back.
Chairman ROSKAM. Mr. Blumenauer.
Mr. BLUMENAUER. Thank you very much for being with us this
afternoon.
There are lots of things to chew on, but, Dr. Paz, I really
appreciate your reference to the legislation we have to try to
make sure that we take care of this disconnect between people
who, in terms of unnecessarily restrictive information, for
prescribing physicians to actually know that somebody has an
opioid addiction problem. I think the legislation that we have
would help remedy that.
Do you have any sense why this is so hard to remedy? Is
this just because any time we are dealing with patient privacy
we are in kind of a never-never land, that it hasn't received a
high enough priority? Are there examples that you or any of the
panelists can help us with to show the disastrous consequences
of a physician not having this information?
Dr. PAZ. So, Congressman, thank you for the question. I
think there are two parts to the answer. First is the general
backdrop of the lack of interoperability of health information
in general. We have real challenges in healthcare in terms of
connecting data that sits in different places between providers
with the patient and often having patient information that is
patient-centric that is usable by a patient to make important
health decisions. That is a challenge that is historical,
longstanding, and, in fact, has become even more complicated
with the use of electronic records to record and retain that
information. So that is one issue. It is the backdrop for the
challenges we have in really improving care in general in terms
of wastefulness.
But the other part of it is the part two reform that I
mentioned in my testimony. HIPAA was written for many, many
good reasons, and, obviously, we are in support of it, as I am
sure everybody is, to protect patient health information. But
at the same time, we have to have modernization of
federalization around health information privacy so that, in
certain circumstances like the one we are talking about today,
providers, physicians have access to information to know if
their patient is abusing or addicted to opioids so that they
can make the important decisions they need to make to assist
and help their patient. Absent that, they are operating without
the useful information they need. And, in fact, that is to the
detriment of their patient.
Mr. BLUMENAUER. Mr. Chairman, I think this is just one
area, but it speaks to a larger set of challenges. But I am
hopeful that, shining a spotlight here, we can help avoid
potentially disastrous consequences, but maybe it will guide us
toward a broader conversation about some adjustments we can
make to protect the confidentiality we all care about but not
make it unduly restrictive in terms of people being able to do
the job for their patients.
Dr. BENYAMIN. Mr. Chairman, may I interject? Very briefly,
this is one of the problems, Congressman, with the prescription
monitoring program, in which we have limitations in accessing
the private data from addiction management facilities. And
those are not reflected in prescription monitoring programs.
And a lot of small mom-and-pop types of pharmacies, they are
not reporting to the data center.
And, again, this is a State-run program. And, you know, as
I mentioned in my testimony, we would like to see a national
program so that the States can interact with each other. People
who live in, you know, border cities, they can easily cross
over and get prescriptions from two different providers and the
providers not even know what is going on.
Chairman ROSKAM. Thank you. Mr. Marchant.
Mr. MARCHANT. Dr. Kletter, I see that your company is
headquartered in Lewisville, Texas.
Mr. KLETTER. That is correct.
Mr. MARCHANT. That area is the entire northern border of my
district. Can you tell me a little bit about the program that
you provide to my constituents in Texas? And tell me a little
bit about the opioid situation in Texas, specifically north
Texas, if you could.
Mr. KLETTER. Sure. I can tell you that the program that we
operate in Lewisville in particular is under our AppleGate line
of business. And AppleGate is an office-based practice that
provides medication-assisted treatment, which is buprenorphine,
along with counseling and drug testing. So it is sort of a
hybrid between an opiate treatment program, which is a very
highly structured program, and a typical office-based practice,
which is a primary care physician prescribing medications.
So what we do there is we prescribe medications and
counseling and we do counseling and do drug testing to--it is a
small number of folks so far. We have been open in Lewisville
for just a short time. We have 12 sites in Texas in total. Most
of those sites are opiate treatment programs. And, again,
opiate treatment programs are the more structured, more
regulated programs where we have more intensive services and we
provide daily medication administration.
The daily medication administration is part of the Federal
regulations that help to prevent diversion of these very
powerful medications. So what that means is a patient will come
into treatment. They will get a history and physical with a
physician. They will be provided a clinical assessment,
generally an ASAM assessment, American Society of Addiction
Medicine assessment, or an Addiction Severity Index assessment.
They will be determined or diagnosed with opioid use disorder,
and they will be provided with the appropriate dose--the
appropriate type of medication and the appropriate dose of
medication, based on a physician's order. And based on that
physician's order, they will then participate--they will
develop a treatment plan with a counselor, and every 90 days,
that treatment plan will be updated so that we can make sure
that they are doing well, they are progressing in treatment.
We will do a monthly random drug test to make sure that
they are not only taking the medication that we are giving them
but that they are also not taking other illicit or prescribed
opiates. And they will get their medication from a nurse every
day who does sort of a very brief assessment to make sure that
the dose is the right dose and that they are progressing well
in treatment and getting some words of encouragement to follow
their treatment plan.
Mr. MARCHANT. Does Texas have an effective opioid policy,
as far as assistance from the State?
Mr. KLETTER. The Medicaid rates for reimbursement for the
services that we provide are not good in and of themselves, but
they have done a great job in using the STR money out of the
CURES grant to supplement that program this year and next,
hopefully. So, generally, the regulatory environment in Texas
is good. Funding could be improved, but they are working on
that, and they are doing better, and we are encouraged that
they have been a good partner.
Mr. MARCHANT. Thank you.
Chairman ROSKAM. Mrs. Black.
Mrs. BLACK. Thank you, Mr. Chairman.
And I appreciate you all being here today. As a nurse for
over 45 years, I have watched this scourge on our society
occur. And I know we talk about chronic pain. We certainly want
to take care of people that have chronic pain; there is no
doubt about that. They suffer. You can see that by their blood
pressures, by their anxiety, by their pulses. But what we did
with this, ``how bad is your pain,'' the smiley face system,
was not a very good thing for us to do, and I am glad that we
have finally stopped doing that.
Thank you, Dr. Benyamin, for what you are doing with the
interventional pain management. And I would like at some point
in time, and I know we don't have enough time here, to talk
with you more about the results that you are getting from that.
What percentage of your patients going through that kind of
treatment have found success? Is there a number that you could
give me on that of the----
Dr. BENYAMIN. I would be glad to provide you with all the
data.
Mrs. BLACK. I would really like that.
Dr. Kletter, I want to go to you and talk to you a little
bit about--or excuse me, Mr. Kletter--or is it Dr. Paz? Which
one of you is doing the program where you are using the
medication-assisted treatment?
Mr. KLETTER. We are.
Mrs. BLACK. Dr. Kletter, okay. What percentage of your
clients have eventually become drug-free with your medication-
assisted treatment? How do you move them to a drug-free
situation?
Mr. KLETTER. So, as I said in my testimony, it is important
to understand that medication--as we think about medication-
assisted treatment, it is important to understand the concept
of opioid use as a chronic disease. And so, like any other
chronic disease, we know that patients who suffer from opioid
use disorder struggle with it in some cases for their entire
life. We have very effective treatment, but we don't have a
cure for the treatment.
And so, generally, our approach is not to encourage people
to get off of treatment immediately. We do encourage folks to
stay in treatment at least a year, and in that way, we know
that--although science tells us that you must stay in treatment
for at least a year to sort of help heal the brain from the
changes that have occurred, we know from science that there are
changes that have occurred in the brain from overuse of
opioids. So we encourage folks to stay in treatment at least a
year. I can tell you that 60 percent of our patients are in
treatment----
Mrs. BLACK. I know my time is going to run out here in just
a second. If I could get more information from you on looking
further out and what all the results are, that would be great.
And then, Ms. Hungiville, I would like to ask you about how
you are using telehealth, since that is something that I am
very interested in.
Ms. HUNGIVILLE. Well, we are piloting a program where, in
the ER, we are trying to get patients when they are in crisis,
in overdose and/or even drug seeking, and making telehealth
available to them to immediately start with medication-assisted
treatment and then get them into counseling and into a program.
Mrs. BLACK. I would love to hear more from you as well.
And, Mr. Chairman, I am asking for a lot of information I
guess will be sent back to your office so that you could share
with us some of the results of what you are doing. Thank you so
much.
Chairman ROSKAM. Thank you. Just a couple questions in kind
of summary.
Dr. Kletter, in your testimony and in your statement, you
used the phrase ``opioid use disorder.'' Is that a term of art?
Is that somehow distinguishing between the word ``addiction,''
and are you communicating something else? I have a brother who
is an emergency physician, and I noticed that at one point, the
emergency physicians began to speak about the emergency
department.
So what is the story behind that phrase, and is there a
subtlety that you are communicating there that we need to know
about, or are these phrases interchangeable with addiction?
Mr. KLETTER. So opioid use disorder is the term that is
used in the Diagnostic and Statistical Manual of Mental
Disorders, the DSM, which is sort of the tool that physicians
use to diagnose disease, psychological disease generally.
So there is a distinction between addiction and dependence.
That is really critical to understand. The difference is, of
course, addiction, which is--so opioid use disorder is what you
might call an addiction, and it is characterized in the DSM by
there being 11 criteria in order to meet the diagnosis of
opioid use disorder.
Two of those are physiological; they are tolerance and
withdrawal. The other nine are behavioral, things like engaging
in behaviors despite negative consequences, compulsive use,
using increasing amounts over time even though you don't intend
to. So there is an important distinction between opioid use
disorder and tolerance--or, sorry, dependence, dependence being
simply using a medication consistently--you could be dependent
on a medication. For example, I take a statin. I am dependent
on that medication to prevent my cholesterol from getting too
high and having a heart attack. So I don't know if that answers
your question.
Chairman ROSKAM. Yes, it does. But there are some
subtleties there that I need to learn more about. So, if you
have any insight on the tutorial, I would be grateful.
Mr. KLETTER. Sure. We are happy to tell you more and invite
you or Mrs. Black or any of the Members of the Subcommittee to
any of our facilities. We are happy to show you around, show
you what we do, and how effective our services are.
Chairman ROSKAM. Okay. That would be helpful.
Dr. Paz, in your testimony, you spoke about intervening for
those who are at risk. How are at risk individuals, patients or
overprescribers identified, and what is the threshold, you
know, based on Mr. Blumenauer's observations about the
sensitivity around privacy and all that sort of stuff? How do
you navigate through identifying someone who is at risk, and
how do you walk through that carefully?
Dr. PAZ. Thank you for the question, Mr. Chairman.
So there are several different ways we do this, and one is
we have access to our members' claims history, in terms of
prescriptions of opioids. And we will find evidence of pharmacy
shopping, physician shopping. Right there, that would be a risk
factor. We have records of his prior history----
Chairman ROSKAM. So you basically have predictive modeling.
I mean, you have that access to those algorithms that say,
``Hey, there is a problem here.''
Dr. PAZ. And then we would intervene if there are
circumstances where that occurs, again, within the boundaries
of HIPAA requirements, certainly.
Chairman ROSKAM. What does that intervention look like?
Dr. PAZ. We have case managers, care managers that we
actually have that intervene with our member, for example.
Chairman ROSKAM. Is it explicit? I mean, is it a call from
a case manager that says, ``I think you have a problem''?
Dr. PAZ. Yeah.
Chairman ROSKAM. Okay.
Dr. PAZ. Yeah. We would certainly--our case managers would
interface or interact with a member that has a set of
conditions that requires some kind of an intervention that we
can offer, not as a provider, though, which is key.
We work with providers, and, again, being mindful of HIPAA
requirements.
Chairman ROSKAM. Say that again. You were just making an
important point, and I didn't quite pick up on it. So the
important point that you are making is a distinction between
providers and carriers, based on what?
Dr. PAZ. So, in terms of prescribing, a provider would
prescribe.
Chairman ROSKAM. Right.
Dr. PAZ. We have access to information that would suggest
overprescribing. And I gave a few examples earlier that putting
in limits on how many days a prescription can be written for
for acute pain, putting in a dosing limit as well. So these are
things that we can do.
We have done other things like partnered with a company,
Pacira, which has produced a nonopioid pain reliever for oral
surgery, post-oral surgery. We have created a partnership with
them. It is a value-based contract that we have with them, so
it is emphasizing quality outcomes for our members that receive
that drug.
But they are now going to receive a nonnarcotic after oral
surgery as opposed to a 30-day supply of a narcotic post-oral
surgery, which, interestingly, in our review of data and
analytics, we find does, sadly, occur. It occurs even after a
routine dental visit, unfortunately. So for a wisdom tooth
extraction.
So there are a number of different things that we can do
including, for example, we have two programs that are
noteworthy. One is the work that we are doing with mothers who
have neonatal abstinence syndrome. We launched this program in
several States. Again, our care managers intervene with mothers
who have been identified as being neonatal abstinence, at risk
for having children born with neonatal abstinence syndrome, and
we put a program in place with ICUs, neonatal ICUs in their
communities to address that.
And, certainly, our program where we distribute naloxone
and make sure that we are working to train first responders in
communities to help members avoid death associated with
overdose and addiction.
Chairman ROSKAM. That is helpful. Thank you.
What is the duration? And this is for the physicians on the
panel. What is the duration that somebody can be taking an
opioid and they become addicted? We have talked about a 7-day
threshold. I have heard that referred to several times.
You know, Doctor, you are shaking your head. There is not a
magic number. What is a threshold? What is a range? What is a
reasonable expectation?
Dr. BENYAMIN. You know, again, it all depends on who is the
patient, what is the pathology behind it, the reason. What is
the reason that the patient is taking the medication? Is it a
patient who just feels aches and pains all over their body, or
is it a patient who has had five low back surgeries and three
neck surgeries and two knee replacements? You know, these are
all different patients. And, you know, we are human beings at
the end of the day. We are not robots. So we react differently
to disease, and we react differently to medications for the
disease. So we have to allow for individualization of these
treatments.
Chairman ROSKAM. In your study and evaluation of this for
any of the four of you, is there a spectrum in terms of
addiction, or does somebody cross a line and they are addicted?
Dr. PAZ. So, in general, that 7-day number that is in the
CDC recommendations is there for a reason, because roughly--and
this is, again, depending on the study you look at--about 14
percent of individuals who are exposed to a week of a narcotic
will become addicted.
Chairman ROSKAM. Fourteen percent. So, in other words, 14
percent of people who are on it 7 days or more, they are
addicted.
Dr. BENYAMIN. And, Mr. Chairman, the psychiatrists will
argue that addiction is a disease in the person; it is not in
the substance. So this is a continuous saga between one side of
this equation and the other.
Chairman ROSKAM. The medical spectrum. Yes, I understand.
Ms. HUNGIVILLE. The dosage is also important, and the CDC
guidelines also say that more than 50 morphine-equivalent
dosages per day puts you at a higher risk of developing
addiction.
Dr. BENYAMIN. Mr. Chairman, if I have to point to one thing
that is missing in a lot of medical specialties, we are good at
writing prescriptions, at prescribing treatments, but we are
not good at monitoring the treatment as far as effect and side
effect.
That is why it is very important that when we prescribe,
that is what our guidelines say--how you need to monitor the
effect and the side effects of medications, that is going to be
the key.
Chairman ROSKAM. That is a good summary. So let me ask each
of you, in closing, if you had to communicate one thing, not
four things, not a handful of things, one thing to this group
today, what would it be? Doctor.
Dr. BENYAMIN. Cut the supply of heroin and synthetic
fentanyl. That is like a weapon of mass destruction affecting
our communities.
Chairman ROSKAM. Got it. Dr. Kletter.
Mr. KLETTER. Increase access to evidence-based treatment
services.
Chairman ROSKAM. Dr. Paz.
Dr. PAZ. Ensure education around use of nonopioid pain
treatments.
Chairman ROSKAM. Okay. Ms. Hungiville.
Ms. HUNGIVILLE. And I would also add limiting dosages of
opioids for acute conditions.
Chairman ROSKAM. Okay. Mr. Thompson.
Mr. THOMPSON. Thank you for indulging me.
I mentioned to the Governor my concern about the treatment
delay in the workers' compensation programs leading to opioid
problems, and it is something I am very, very interested in.
I have seen a lot of anecdotal evidence that this is true.
In my State of California, there is just a long waiting period.
Everybody is denied--a lot of people are denied the procedures
that the medical profession recommends, so it stretches out the
time that they are on painkillers. And I have just seen too
many people who, because of this, become addicted.
And I am looking at some different things to try to deal
with this. So, if any of you have any information that would
help me out in that, would you please send it to me?
Chairman ROSKAM. We have been joined by our former
colleague, Ed Whitfield, a great American from Kentucky and
former Chairman of our partner Committee, the Energy and
Commerce Committee, which has a lot to do with the solutions
here. So it is good to have him back.
For the record, Members are advised that they have 2 weeks
to submit written questions that can be answered later in
writing, and those questions and your answers will be made part
of the formal hearing record.
Finally, two things: Number one, thank you for your time.
You have been very generous with your time today, and I know it
is an adventure to schlepp out here and all that, so thank you
for doing that and for the time that you put into your
testimony. It was very helpful.
Second, if you think of things subsequent to this, whether
you are flying home, driving around, whatever you are doing, in
the next several weeks or months, and you think, I wish I had
said that or I have this article, and I think those people
would benefit from it, send it to us. And I will make sure that
it is distributed.
You get the sense of the caliber of these people. These are
serious, thoughtful people that are solution-oriented. We are
not looking for pen pals, if you know what I am saying. But,
things that you think we should be reading, would be very, very
helpful.
So, on behalf of the whole Subcommittee, I want to thank
you for your time today and look forward to continuing to
interact with you in the future. Thank you.
The Committee stands adjourned.
[Whereupon, at 6:31 p.m., the Subcommittee was adjourned.]
[Questions for the Record follow:]
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